Abnormal Psychology Oltmanns and Emery Chapter Ten Eating Disorders presented by: Mani Rafiee

1. Abnormal PsychologyOltmanns and EmeryChapter TenEating Disorders presented by:Mani Rafiee

2. Chapter Outline • Symptoms of Anorexia • Symptoms of Bulimia • Diagnosis of Eating Disorders • Frequency of Eating Disorders • Causes of Eating Disorders • Treatment of Anorexia Nervosa • Treatment of Bulimia Nervosa • Prevention of Eating Disorders

3. Overview • Eating disorders are severe disturbances in eating behavior that result from the sufferer’s obsessive fear of gaining weight. • DSM-IV-TR lists two major types of eating disorders: anorexia nervosa and bulimia nervosa. • The most obvious characteristic of anorexia nervosais extreme emaciation, or more technically, the refusal to maintain a minimally normal body weight.

4. Overview • Bulimia nervosa is characterized by repeated episodes of binge eating, followed by inappropriate compensatory behaviors such as self-induced vomiting, misuse of laxatives, or excessive exercise. • Both anorexia and bulimia are about 10 times more common among females than males, and they develop most commonly among women in their teens and early twenties.

5. Symptoms of Anorexia Refusal to Maintain a Normal Weight • The most obvious and most dangerous symptom of anorexia nervosa is a refusal to maintain a minimally normal body weight. • Anorexia nervosa often begins with a diet to lose just a few pounds. • The young woman weighs near her healthy body weight, and she decides to lose a little weight, perhaps to fit into some new clothes.

6. Symptoms of Anorexia Refusal to Maintain a Normal Weight (continued) • The diet goes awry, however, and losing weight eventually becomes the key focus. • Weight falls well below the normal range, and often plummets to dangerously low levels. • DSM-IV-TR contains no formal cutoff as to how thin is too thin, but suggests 85 percent of expected body weight as a rough guideline.

7. Symptoms of Anorexia Disturbance in Evaluating Weight or Shape • A second defining symptom of anorexia nervosa is a perceptual, cognitive, or affective disturbance in evaluating one’s weight and shape. • Many individuals deny problems with their weight.

8. Symptoms of Anorexia Disturbance in Evaluating Weight or Shape (continued) • Other people with the disorder suffer from a disturbance in the way body weight or shape is experienced. • Sometimes this may include a distorted body image,an inaccurate perception of body size and shape.

9. Symptoms of Anorexia Fear of Gaining Weight • An intense fear of becoming fat is a third central characteristic of anorexia. • The fear may grow more intense as the individual loses more weight.

10. Symptoms of Anorexia Cessation of Menstruation • Amenorrhea, the absence of at least three consecutive menstrual cycles, is the fourth and final defining symptom of anorexia nervosa in females. • The amenorrhea has led to speculation about the role of sexuality and sexual maturation in causing anorexia nervosa. • However, the amenorrhea typically is a reaction to the physiological changes produced by anorexia nervosa, specifically a low level of estrogen secretion, and not a symptom that precedes the disorder.

11. Symptoms of Anorexia Medical Complications • People with anorexia commonly complain about constipation, abdominal pain, intolerance to cold, and lethargy. • In addition, the skin can become dry and cracked, and some people develop lanugo, a fine, downy hair, on their face or trunk of their body. • Broader medical difficulties may include anemia, infertility, impaired kidney functioning, cardiovascular difficulties, dental erosion, and osteopenia (bone loss).

12. Symptoms of Anorexia Medical Complications (continued) • A particularly dangerous medical complication is an electrolyte imbalance, a disturbance in the levels of potassium, sodium, calcium, and other vital elements found in bodily fluids. • Electrolyte imbalance can lead to cardiac arrest or kidney failure.

13. Symptoms of Anorexia Struggle for Control • People with anorexia nervosa often take great pride in their self-denial, feeling like masters of control. • Some theorists speculate that the disorder actually develops out of a desperate sense of having no control. • Excessively compliant “good girls” may find that obsessively regulating their diet allows them to be in charge of at least one area of their lives.

14. Symptoms of Anorexia Comorbid Psychological Disorders • Anorexia nervosa may be associated with other psychological problems, particularly obsessive–compulsive disorder, obsessive–compulsive personality disorder, and depression. • In many cases, however, these comorbid psychological problems may be reactions to anorexia, not causes of it. • Anorexia often co-occurs with the symptoms of bulimia.

15. Symptoms of Bulimia • Many people with bulimia nervosa have a history of anorexia nervosa. • Depression also is commonly associated with the disorder.

16. Symptoms of Bulimia Binge Eating • Binge eating is defined in DSM-IV-TR as eating an amount of food in a fixed period of time, for example, less than 2 hours, that is clearly larger than most people would eat under similar circumstances. • Binges may be planned in advance, or they may begin spontaneously. • In either case, binges typically are secret.

17. Symptoms of Bulimia Binge Eating (continued) • Binge eating is commonly triggered by an unhappy mood, which may begin with an interpersonal conflict, self-criticism about weight or appearance, or intense hunger following a period of fasting. • A key feature of binge eating is a sense of lack of control during a binge.

18. Symptoms of Bulimia Inappropriate Compensatory Behavior • Almost all people with bulimia nervosa engage in purging,designed to eliminate the consumed food from the body. • The most common form of purging is self-induced vomiting; as many as 90 percent of people with bulimia nervosa engage in this behavior. • Other less common forms of purging include the misuse of laxatives, diuretics (which increase the frequency of urination), and, most rarely, enemas.

19. Symptoms of Bulimia Inappropriate Compensatory Behavior (continued) • Ironically, purging has only limited effectiveness in reducing caloric intake. • Vomiting prevents the absorption of only about half the calories consumed during a binge, and laxatives, diuretics, and enemas have few lasting effects on calories or weight. • Inappropriate compensatory behaviors other than purging include extreme exercise or rigid fasting following a binge.

20. Symptoms of Bulimia Excessive Emphasis on Weight and Shape • People with bulimia nervosa place excessive emphasis on body shape and weight in evaluating themselves. • Their self-esteem, and much of their daily routine, center around weight and diet. • The individual’s sense of self is linked too closely to appearance instead of personality, relationships, or achievements.

22. Symptoms of Bulimia Comorbid Psychological Disorders • Depression is common among individuals with bulimia nervosa, especially those who self-induce vomiting. • Other disorders that may co-occur with bulimia nervosa include anxiety disorders, personality disorders (particularly borderline personality disorder), and substance abuse, particularly excessive use of alcohol and/or stimulants.

23. Symptoms of Bulimia Medical Complications • Repeated vomiting can erode dental enamel, particularly on the front teeth, and in severe cases teeth can become chipped and ragged looking. • Repeated vomiting can also produce a gag reflex that is triggered too easily and perhaps unintentionally. • One consequence of the sensitized gag reflex—one that is just beginning to be reported in the scientific literature—is rumination:the regurgitation and rechewing of food.

24. Diagnosis of Eating Disorders Brief Historical Perspective • Isolated cases of eating disorders have been reported throughout history. • In fact, the term anorexia nervosa was coined in 1874 by a British physician, Sir William Withey Gull. • Still, the history of professional concern with the disorders is very brief. • References to eating disorders were rare in the literature prior to 1960, and the disorders have received scientific attention only in recent decades.

25. Diagnosis of Eating Disorders Brief Historical Perspective (continued) • The term bulimia nervosa was used for the first time only in 1979. • The diagnoses of anorexia nervosa and bulimia nervosa first appeared in DSM in 1980 (DSM-III). • Although the diagnostic criteria have changed somewhat, the same eating behaviors remain as the central features of these disorders.

26. Diagnosis of Eating Disorders Contemporary Classification • DSM-IV-TR includes two subtypes of anorexia nervosa. • The restricting type includes people who rarely engage in binge eating or purging. • In contrast, the binge eating/purging type is defined by regular binge eating and purging during the course of the disorder.

28. Diagnosis of Eating Disorders Contemporary Classification (continued) • Bulimia nervosa is divided into two subtypes in DSM-IV-TR. • The purging type is characterized by the regular use of self-induced vomiting or the misuse of laxatives, diuretics, or enemas. • The individual with the nonpurging type of bulimia nervosa does not regularly purge but instead attempts to compensate for binge eating with fasting or excessive exercise.

31. Diagnosis of Eating Disorders Contemporary Classification (continued) • There has been some debate about whether other eating problems should be included in the DSM-IV-TR list of eating disorders. • Binge eating disorder is one problem that was given extensive consideration. • The proposed disorder involves episodes of binge eating much like those found in bulimia nervosa but without compensatory behavior.

32. Diagnosis of Eating Disorders Contemporary Classification (continued) • Research has demonstrated that binge eating is associated with a number of psychological and physical difficulties other than anorexia nervosa and bulimia nervosa. • Among these problems is obesity, or excess body fat, a circumstance that roughly corresponds with a body weight 20 percent above the expected weight. • Calling obesity a “mental disorder” is controversial, especially given the high prevalence of overweight individuals in the United States and throughout the world.

33. Feeding and Eating Disordersin DSM 5 • Rename the category • pica and rumination disorder can be made for individuals of any age • feeding disorder of infancy or early childhood has been renamed avoidant/restrictive food intake disorder • Anorexia Nervosa: the requirement for amenorrhea has been eliminated. • Binge-Eating Disorder (new)

34. Frequency of Eating Disorders • Estimates of the epidemiology of anorexia and bulimia vary, but it is clear that the prevalence of both disorders has increased dramatically since the 1960s and 1970s. • DSM-IV-TR indicates that lifetime prevalence of anorexia nervosa is 0.5 among females, a figure that is consistent with other estimates.

35. Frequency of Eating Disorders • Recent decades also seem to have witnessed a torrent of new cases of bulimia nervosa. • Bulimia nervosa is far more common than anorexia nervosa. • According to DSM-IV-TR, bulimia nervosa occurs among 1 to 3 percent of women, a rate that is two to six times the number of cases of anorexia nervosa. • Moreover, the prevalence of subclinical bulimia—occasional binge eating and/or purging—is far greater than the number of cases that meet DSM-IV-TR criteria for bulimia nervosa.

36. Frequency of Eating Disorders Standards of Beauty • Popular attitudes about women in the United States tell us that “looks are everything,” and thinness is essential to good looks. • In contrast, young men are valued as much for their achievements as for their appearance, and, the ideal body type for men is considerably larger than for women.

37. Frequency of Eating Disorders Standards of Beauty (continued) • The growing prevalence of eating disorders may be explained by changing standards of beauty. • Marilyn Monroe, the movie idol of the 1950s, is chunky by today’s standards.

38. Frequency of Eating Disorders Age of Onset • Both anorexia and bulimia nervosa typically begin in late adolescence or early adulthood. • A significant minority of cases of anorexia nervosa begin during early adolescence, particularly as girls approach puberty.

39. Causes of Eating Disorders Social Factors • Standards of beauty and the premium placed on young women’s appearance contribute to causing eating disorders. • Troubled family relationships may be another factor that increases vulnerability. • Young people with bulimia nervosa report considerable conflict and rejection in their families, difficulties that also may contribute to their depression.

40. Causes of Eating Disorders Social Factors (continued) • In contrast, young people with anorexia generally perceive their families as cohesive and nonconflictual. • Although the families of young people with anorexia nervosa appear to be well functioning, some theorists see the families as being too close—asenmeshed families, families whose members are overly involved in one another’s lives.

41. Causes of Eating Disorders Social Factors (continued) • According to the enmeshment hypothesis, young people with anorexia nervosa are obsessed with controlling their eating, because eating is the only thing they can control in their intrusive families. • Child sexual abuse is another family difficulty that might contribute to the development of eating disorders.

42. Causes of Eating Disorders Psychological Factors • Hilde Bruch viewed a struggle for control as the central psychological issue in the development of eating disorders. • Perfectionismis another term for the endless pursuit of control described by Bruch. • Perfectionists set unrealistically high standards, are self critical, and demand a nearly flawless performance from themselves.

43. Causes of Eating Disorders Psychological Factors (continued) • Young people with eating disorders may also try to control their own emotions excessively, perhaps as a result of their constant attempt to please others instead of themselves. • The result may be a lack of introceptive awareness—recognition of internal cues, including various emotional states as well as hunger.

44. Causes of Eating Disorders Psychological Factors (continued) • Depression is commonly comorbid with eating disorders, particularly bulimia nervosa. • Research also shows that antidepressant medications reduce some symptoms of bulimia nervosa. • Bulimia thus appears to be a reaction to depression in some cases.

45. Causes of Eating Disorders Psychological Factors (continued) • In other cases, however, depression may instead be a reaction to bulimia nervosa and especially to anorexia nervosa. • Some experts suggest that depressive symptoms, and not necessarily clinical depression, play a role in the onset of eating disorders. • Low self-esteem is a particular concern.

46. Causes of Eating Disorders Psychological Factors (continued) • A negative body image, a highly critical evaluation of one’s weight and shape, has long been thought to contribute to the development of eating disorders. • Several longitudinal studies have found negative evaluations of weight, shape, and appearance to predict the subsequent development of disordered eating.

47. Causes of Eating Disorders Biological Factors • Weight regulation is a result of the interplay among behavior (e.g., energy expenditure, eating), peripheral physiological activity (e.g., digestion, metabolism), and central physiological activity (e.g., neurotransmitter release). • The body strives to maintain weight around certain weight set points, fixed weights or small ranges of weight.

48. Causes of Eating Disorders Biological Factors (continued) • If weight declines, hunger increases and food consumption goes up. • There is a slowing of the metabolic rate, the rate at which the body expends energy, and movement toward hyperlipogenesis, the storage of abnormally large amounts of fat in fat cells throughout the body. • The body does not distinguish between intentional attempts to lose weight and potential starvation.

49. Causes of Eating Disorders Biological Factors (continued) • Other evidence suggests that genetic factors contribute to eating disorders. • Finally, several neurophysiological measures are correlated with eating disorders, including elevations in endogenous opioids, low levels of serotonin, and diminished neuroendocrine functioning. • Most of these differences in brain functioning, however, appear to be effects of eating disorders and not causes of them.

50. Causes of Eating Disorders Integration and Alternative Pathways • There are many pathways to developing an eating disorder. • Eating disorders are best understood in terms of a systems approach.