Eating disorders: a challenge for sufferers, families and caretakers

1. Eating disorders: a challenge for sufferers, families and caretakers Dr Johan Vanderlinden Eating Disorder Unit UPC KULeuven Campus Kortenberg and Faculty of Psychology KULeuven Belgium

2. Summary of Lecture • What kind of eating disorders exist? • What are the causes? How does ED’s develop? • What are the most evidence-based treatments? • How can teachers/student coaches help? • Questions

3. Literatuur • Johan Vanderlinden (2005). Anorexia nervosa overwinnen in 13 stappen. Tielt: uitgeverij Lannoo. • Johan Vanderlinden (2008). Boulimie en eetbuien overwinnen in 10 stappen. Tielt: uitgeverij Lannoo.

4. Different types of Eating Disorders • Anorexia nervosa : two types • Bulimia Nervosa: two types • Eating Disorders Not Otherwise Specified (EDNOS): Binge Eating Disorder

5. Characteristics of Anorexia Nervosa • Low body weight (Quetelet Index<18.5) • Intense fear of gaining weight • Disturbance in the way one’s body is experienced + denial of seriousness of the current low body weight • Amenorrhoea for at least 3 months • Two types: restricting and binge eating/purging type

6. Quetelet Index is ontworpen door Lambert Adolphe Jacques Quételet (Gent 1796- Brussel 1874) was een Belgischastronoom, wiskundige, statisticus en socioloog. Hij was een van de eersten die statistische methoden in de sociale wetenschappen toepaste Quetelet Index of BMI

7. Characteristics of Bulimia Nervosa • Recurrent episodes of binge eating (on average 2 times a week during 3 months) • Sense of lack of control over eatingduring the binge episode • Recurrent inappropriate compensatory behaviour to prevent weight gain (vomiting, laxative abuse, or excessive exercise) • Self-evaluation is unduly influenced by body shape and weight • Purging and non-Purging type

8. EDNOS: Binge Eating Disorder • Binge eating without compensatory behaviors • Hence mostly a problem of obesity is developed

9. Characteristics of EDNOS: Binge Eating Disorder • Binge eating episodes are associated with three (or more) of the following: (1) eating much more rapidly than normal (2) eating until uncomfortable full (3) eating large amount of foods when not feeling physically hungry (4) eating alone because of being embarrassed by how much one is eating (5) feeling disgusted with oneself, depressed, or very guilty after overeating

10. What about Binge Drinking? • No eating disorder • But it deserves our concern and attention • In USA in some campuses: binge/purge parties are organised • Binge drinking certainly is a problem also in Belgium

11. Other Psychological characteristics • Over evaluation of importance of weight • People with eating disorders judge themselves largely or exclusively in terms of shape, weight and eating control (and often all three) • Most of the other clinical features of eating disorders derive from this ‘core’ psychopathology

12. Other Psychological characteristics • Low self-esteem • Perfectionism • Directed towards pleasing other’s needs • Depression • Anxiety/avoidant/maturity fears • Obsessive compulsive (both thoughts and behaviours)

13. Other Psychological characteristics • Social isolation (interpersonal problems) • Comorbidity: alcohol, drugs • Automutilation • Post-traumatic stress reactions (sexual/emotional abuse)

14. In Anorexia Nervosa Abnormally slow heart rate and low blood pressure Reduction of bone density (osteoporosis) Muscle loss and weakness Severe dehydratation (risk kidney failure) Fainting, fatigue Dry hair and skin Growth of hair called lanugo all over the body, in order to keep the body warm Low body temperature In Bulimia Nervosa Electrolyte imbalances leading to irregular heartbeats Potential gastric rupture Inflammation /possible rupture of the oesophagus Tooth delay (acids of frequent vomit) Chronic irregular bowel movements and constipation Peptic ulcers and pancreatitis What are the health consequences/risks?

15. What are the health consequences/risks? • In binge eating disorder • High blood pressure • High cholesterol levels • Heart disease as a result of high triglyceride levels • Type II diabetes mellitus • Gallbladder disease

16. How many women develop an eating disorder ? • Anorexia nervosa: 0.5-1% of female population age 10-25 • Bulimia nervosa: 1-2 % of female population age 10-25 • Binge Eating Disorder: 2-4% of population • Hence we can say that 1 in 20 students is at high risk to develop a severe eating disorder!!

17. Studie naar voorkomen van eetbuien van Vlaamse studentes (n=110) • Studenten middelbaar onderwijs (n=38), studenten psychologie/farmacie/geneeskunde (n=32) en studenten hogeschool toerisme (n=40) • X leeftijd = 20.3 (sd=3.2) • 10% Quetelet index lager dan 18.5 • 10% Quetelet index hoger dan 25

18. Hoeveel studentes met eetbuien??*Vanderlinden, J. (1999).Welke Factoren lokken eetbuien uit? T Direct Therapie,19, 304-314. • 45 studentes (41%) rapporteren last te hebben van eetbuien • 16 studentes (15%) geven aan dagelijks last te hebben van eetbuien • Voornaamste uitlokkers: ik verveelde me ik voelde me depressief ik voelde me angstig ik had honger ik voelde een drang naar zoetigheden ik voelde me alleen ik voelde me gespannen

19. How many patients recover? • Eating disorders are very severe psychiatric/psychological disorders (highest mortality rate of all psychiatric disorders) • On average it takes 6 years between onset and recovery • BUT: only 40-50 % fully recover • 25% develops a chronic eating disorder

20. What are the causes of eating disorders?? • We still know very little • General: highest risk factor to develop an eating disorder is being female and young age • Approx. 95% of all eating disorder patients are female between age 14 and 25 • Unfortunately: we do not know anything why women are so vulnerable to develop Eating Disorders??????

21. What are the causes of possible links of eating disorders? • Bio-psycho-sociocultural model is proposed to understand the origin of anorexia nervosa • BUT : most important Historical landmark: the Minnesota semi-starvation experiment (Keyes et al, 1950)

22. Historical landmark: the Minnesota semi-starvation experiment (Keyes et al, 1950) • The primary objective of the Minnesota Starvation Experiment was to study in detail the physical and psychological effects of prolonged, semi-starvation on healthy men and their subsequent rehabilitation from this condition. To achieve these goals, the 12-month study was parsed into four distinct phases:

23. Historical landmark: the Minnesota semi-starvation experiment (Keyes et al, 1950) • Control Period (12 weeks): standardization period of approximate 3.200 calories of food each day. • Semi-Starvation Period (24 weeks): During the 6-month semi-starvation period, each subject’s dietary intake was cut to approximately 1.800 calories per day. • Restricted Rehabilitation Period (12 weeks): The participants were divided into four groups of eight men; each group received a strictly-controlled rehabilitation diet consisting of one of four different caloric energy levels. • Unrestricted Rehabilitation Period (8 weeks): For the final rehabilitation period, the caloric intake and food content was unrestricted, but carefully recorded and monitored

24. Historical landmark: the Minnesota semi-starvation experiment (Keyes et al, 1950) • Among the many conclusions from the study was the confirmation that prolonged semi-starvation produces significant increases in mood (depression) and important personality changes • most of the subjects experienced periods of severe emotional distress and depression

25. Historical landmark: the Minnesota semi-starvation experiment (Keyes et al, 1950) • Extreme reactions to the psychological effects during the experiment including self-mutilation Many reported binge eating during the rehabilitation phase • Participants exhibited a dramatic increase in food preoccupation, both during the starvation period and the rehabilitation phase • Sexual interest was drastically reduced • The volunteers showed signs of social withdrawal and isolation • The participants reported a decline in concentration, comprehension and judgment capabilities

26. The Minnesota semi-starvation experiment (Keyes et al, 1950) • The profound effects of starvation also illustrate the tremendous adaptive capacity of the human body and the intense biological pressure on the organism to maintain a relatively consistent body weight. This makes complete evolutionary sense.

27. Conclusion • Severe and prolonged dietary restriction can lead to serious physical and psychological complications. Many of the symptoms once thought to be primary features of anorexia nervosa are actually symptoms of starvation. • Keys, A., Brozek, J., Henschel, A., Mickelsen, O., & Taylor, H. L., The Biology of Human Starvation (2 volumes, 1350 p.), University of Minnesota Press, 1950.

28. Biological origins/roots?? • These days specialists believe that anorexia is only genetically based • Most important findings in mono-zygotic twins: in case one sister develops anorexia, the other sister has a risk of more then 50% to develop anorexia. In dyzygotic twins, risk is much lower.

29. Biological origins/roots?? • Lifetime risk for developing an eating disorder is 10 times greater for relatives of those who have eating disorders than for relatives of those who don't • A strong going together exists between eating disorders and depression/anxiety disorders (80%) • Other researchers demonstrate the importance of the development of body fat and BMI during childhood (genetically based) • Children with overweight: higher risk for developing an eating disorder

30. Biological origins/roots?? • A new line of research is focusing on a genetically-based cognitive rigidity • Neuropsychological studies have shown that patients with AN have difficulties in cognitive flexibility: these laboratory based findings have been used to develop a clinical intervention based on Cognitive Remediation Therapy (CRT) which aims to use cognitive exercises to strengthen thinking skills • Perfectionism and obsessive/compulsive traits in the parents

31. Conclusion on biological roots • A person's unique combination of genes may ultimately make an individual more (or, alternatively, less) susceptible to developing an eating disorder

32. Psychological origins/roots?? • Many different theories • (1) Fear for having a normal weight • (2) Fear for becoming an adult and giving up childhood • Why? the amazing number of stressors that arise, especially for young women, at this time. Bodies change in early adolescence, so those who feel pressure from the demands of getting older may delay physical development through anorexia. The lack of nutrition slows sexual development and can even hinder growth in height.

33. Specific stressors/pressures for students • At the beginning: low self-esteem and perfectionism • When starting university: many mixed feelings and emotions • Not all students are prepared for such an important life change • Anxious/uncertain about their future, anxious for becoming adult and taking on the extra responsibilities • Starting new contacts and develop new friendships can be very frightening

34. Specific stressors/pressures for students • Some students are totally unprepared and forced by their parents • Big change: leaving behind the things (families, friends, home, their own room, etc…) that may have helped them to feel secure • From the very beginning: high pressures (study load, stress of exams, worry about being accepted, part time job ,….)

35. Eating disorders as an escape from all these pressures • Increased vulnerability to develop eating disorders • Anorexia nervosa/ bulimia nervosa as a way to block out the changes/avoidance! • After some time, preoccupation/obsession with body weight increases • Weight loss/controlling of the weight is only way they can be successful

36. Eating disorders as an escape from all these pressures • ‘Emotional eating’ in case of bulimia nervosa as a way to cope with negative emotions • During the binge/purge all the negative feelings disappear • Food brings a ‘false’ sense of security and can also comfort them

37. Psychological origins/roots?? • (3) Unrealistic perceptions of the body/weight, oneself, the world • (4) Post-traumatic reactions (30-40%)

38. Post-traumatic reactions in students? • Rape or sexual harassment • Example 21 year old women develops anorexia after rape • Often rape is not reported: feeling guilty about what happened; fear of not being believed, feel too ashamed about what happened • In USA: some rich students hire body guards!!

39. My question: • Do students know where to go in case of rape, sexual harassment? • Do student coaches have a program to deal with these problems? • Information/Education? • Do students know where to ask for help/support in the case of eating disorder problems?

40. Psychological origins/roots?? • (5) Family factors causing ED’s?? • This model was very popular end of 70ties-beginning 80ties • Now again a lot a research • Major conclusion: a ‘typical’ eating disorder family does not exist

41. Psychological origins/roots?? • Within a family therapeutic model the eating disorder is considered NOT as an individual problem but as a problem related to the family system or a symptom of a dysfunctional family system

42. Some observations in families with eating disorders • Strong conflict avoidance • Absence of open communication • A tense and critical family atmosphere (criticizing one another) • An education stressing the importance of ‘good school results and success’ • A strong attachment between the ED child and one parent (often the mother), while a distant exists towards the other parent • Lack of attachment

43. Families and students • Students growing up in families who are highly overprotective • Students growing up in invalidating family environments (neglect/emotional abuse) • Both groups not prepared for this big change

44. Socio-cultural roots/risks? • Quite controversial: but agreement on some risk factors exist • (1)society or environment which places great importance on physical appearance, and (2) a society or environment which equates thinness with achievement or success. • Both of these factors are evident in Western society and may increase the risk for developing an eating disorder in vulnerable young women

45. Conclusion about risk factors • There is no single cause of eating disorders such, but rather it is believed that a variety of biological, psychological and socio-cultural factors make young women at risk for the development of an eating disorder. • This combination may be different for each individual suffering from an eating disorder.

46. What about Treatment? • Treating eating disorders means addressing medical, psychological, behavioral, and social concerns associated with the struggle. Each of these aspects requires specific treatments aimed at lasting change based on more than force of will • Hence a multidisciplinary approach is mostly indicated

47. How to approach a student with an eating disorder? • I believe that few students will spontaneously ask for help for the eating disorder • Big problem is a lack of motivation for most ED patients to ask for help • There is always an important denial of the seriousness of the problem

48. How to approach a student with an eating disorder? Indirect signals: • Students will ask for help for other complaints: • study/concentration problems/rigidity feeling lonely/depressed problems with planning because of perfectionism and fear of failure sleeping problems tiredness/chronic fatigue extreme moodiness social isolation compulsive exercise • and….

49. How to approach a student with an eating disorder? What signals can be observed? • All the just mentioned complaints need further exploration: • In anorexia nervosa: low body weigh • In bulimia nervosa: no signs/hidden disorder • In binge eating disorder: overweight

50. How to approach a student with anorexia nervosa? • Very, very difficult • BUT: how far may it go until we stay STOP?? • What is the responsibility of the coaches/professors?? • Try to find out if the student is aware or not aware of the problem