Eating Disorders

Eating Disorders Eating Disorders

Anorexia Nervosa (AN) • Self-inflicted starvation. • Peaks occur between 14 and 18 years. • Average age of onset is 17. • Most cases develop before age 25. • 10% of hospitalized patients die due to complications. Eating Disorders

Anorexia Nervosa • Sharp reduction of food intake. • Obsessed by the need to be thin, to avoid being “fat” • Recommended amount of calories for adolescent girls is 1500-1800 calories/day. • Average daily food intake of women with AN is 400-800 calories. • Very few anorexics are overweight (5%). • Common in women who are already considered slim by peers. Eating Disorders

Prevalence • 90-95% of patients are female. • Adolescent females prevalence from 5-20%. • Youngest known patient: 6 years old. • Tends to occur in homosexual more than heterosexual males. Eating Disorders

Effects on Prevalence National rates are affected by social factors: • Value the broadcast media places on thinness. • Value society places on thinness. • More prevalent in industrialized countries. • More common in families with a high socioeconomic status. • Very much a first world mental disorder. Eating Disorders

Case study • A 14-year old female athlete began high school at the normal weight of 101 lbs. and a height of 65 inches. • She participated in track and basketball. Soon after beginning her freshman year she began to exercise compulsively. She also restricted her food intake. • Over the course of the year her weight dropped to 93 lbs. Her parents sought to intervene in her destructive behavior. She participated in individual as well as family counseling. • Despite seeing a dietician her weight continued to drop and she soon weighed about 84 lbs. Eating Disorders

Case study • She had been hospitalized and several times doctors had tried nasogastric tube feedings to increase her weight. These were unsuccessful because the patient would remove the feeding tube. Her weight had fallen to less then 75% of her ideal body weight. • By the time she was 15, the patient was referred to a psychiatrist who realized that the patient was exhibiting signs of obsessive compulsive disorder. Further counseling uncovered a history of OCD symptoms as far back as the age of eight. Eating Disorders

AN Profile • Parents describe them as problem-free children. • Often popular, excellent students. • Perfectionistic, intellectually bright. • Hold a negative perception of themselves. • Inflexible, overly sensitive, emotionally restrained, and introverted. • Commonly have obsessive-compulsive behaviours such as ritualized cleaning or cooking. • Distorted body image. Eating Disorders

DSM-IV Criteria A. Refusal to maintain body weight at or above a minimally normal weight for age and height e.g., weight loss leading to maintenance of body weight less than 85% of that expected; or failure to make expected weight gain during period of growth, leading to body weight less than 85% of that expected. Eating Disorders

DSM-IV Criteria B. Intense fear of gaining weight or becoming fat, even though they are underweight. C. Disturbance in the way in which one's body weight or shape is experienced, undue influence of body weight or shape on self-evaluation, or denial of the seriousness of the current low body weight. D. In postmenarcheal females, amenorrhea • the absence of at least three consecutive menstrual cycles. Eating Disorders

DSM-IV Criteria • Restricting Type: the person has not regularly engaged in binge-eating or purging behavior • Binge-Eating/Purging Type: the person has regularly engaged in binge-eating or purging behavior • (i.e., self-induced vomiting or the misuse of laxatives, diuretics, or enemas) Eating Disorders

Etiology • A specific environmental trigger, usually with a sudden onset, setting off pattern of reduced eating and obsessively exercising. • Many maladadptive personality traits (obsessive-compulsive, social phobia) predate the onset of AN • remain following weight normalization. Eating Disorders

Pathology of Undernourishment • Wasting of muscle tissue occurs • May be uncomfortable for them to sit. • Immune system deficits • Poor temperature regulation • Electrolyte imbalance • Wearing down of tooth enamel • Menstruation ceases • Even after recovery, lifelong health problems occur in 80% of patients Eating Disorders

Bulimia Nervosa (BN) • Binging: ingestion of abnormally high quantities of food • 1500 – 55000 calories. • May be a daily occurrence • Are aware that binging is abnormal but cannot control behaviour. 2. Purging: vomiting, laxatives, or excessive exercise. • May replace purging with fasting. • Usually close to appropriate weights. • Extreme guilt and concern with becoming fat. Eating Disorders

Prevalence • Difficult to determine since Bulimics hide their behaviour, and since eating in public is appropriate. • 1-3% of adolescent females are affected. • Up to 20% in college age females. • Peaks in early adulthood. • Again, less common in males. • Often associated with eating problems in childhood, as well as depression, early childhood trauma, addictions. • May be common in certain professions (dancers, athletes, models) Eating Disorders

Case Study • “Carla’s” bulimic behavior began at age 11 years after many unsuccessful attempts to lose weight via caloric restriction and exercise. Carla is of average height and above average weight for age. • Her personal sense of body dissatisfaction was intensified several years ago by external pressure from her school coach, peers, and family to lose weight. Carla was frustrated by her dieting attempts since her caloric restriction resulted in food cravings and binges due to intense hunger. Eating Disorders

Case Study • Her girlfriends at school told her that she could be successful at weight loss and not have to restrict food intake by using laxatives and vomiting after food consumption. Carla and her friends began to plan purging activities and food binges together to prevent weight gain and satisfy their hunger. Eating Disorders

Case Study • In addition to this behavior, Carla continued to exercise regularly. Her bulimic behavior caused her to lose 14 pounds in four weeks. Unaware of her food addiction, her family and coach expressed great pride in her weight loss. The attention and encouragement further reinforced her behavior and intensified her desire for thinness. Eating Disorders

Case Study • Carla’s bulimia progressed rapidly. Within a year of onset she was bingeing and purging as much as five times a day with an average of 3,000 calories at each binge. Eventually, it became increasingly difficult for Carla to focus on her school work and she withdrew from many social activities. Eating Disorders

Case Study • Her boyfriend recognized these changes in her personality and insisted she talk to the school nurse for an evaluation. Carla refused to see the school nurse and tried to assure him that her bulimic behavior was under control. Eating Disorders

Case Study • At the same time, some of Carla’s girlfriends became increasingly concerned about her condition. They expressed their concern about Carla with the school nurse and pleaded with Carla to talk with the nurse. Carla reluctantly conceded. Eating Disorders

DSM-IV Criteria A. Recurrent episodes of binge eating. (1) eating, in a discrete period of time (e.g., within any 2-hour period), an amount of food that is definitely larger than most people would eat during a similar period of time and under similar circumstances. (2) a sense of lack of control over eating during the episode (e.g., a feeling that one cannot stop eating or control what or how much one is eating). Eating Disorders

DSM-IV Criteria B. Recurrent inappropriate compensatory behavior in order to prevent weight gain, such as self-induced vomiting; misuse of laxatives, diuretics, enemas, or other medications; fasting; or excessive exercise. C. The binge eating and inappropriate compensatory behaviors both occur, on average, at least twice a week for 3 months. D. Self-evaluation is unduly influenced by body shape and weight. E. The disturbance does not occur exclusively during episodes of Anorexia Nervosa. Eating Disorders

DSM-IV Criteria • Purging Type: the person has regularly engaged in self-induced vomiting or the misuse of laxatives, diuretics, or enemas  • Nonpurging Type: the person has used other inappropriate compensatory behaviors, such as fasting or excessive exercise, but has not regularly engaged in self-induced vomiting or the misuse of laxatives, diuretics, or enemas Eating Disorders

Neuropathology in AN 1. In AN, imaging studies show frontal and limbic dysfunction (Herholz, 1996; Takano et al., 2001): • hypoperfusion (underactive) in the caudate and anterior cingulate • hyperperfusion (overactive) in medial temporal and thalamic regions 2. “Pseudoatrophy” of the brain • Malnutrition does affect overall brain size • Reduction the size of neurons (gray matter) Eating Disorders

Neuropathology Serotonin Abnormalities • Especially in cingulate, mesial temporal areas • Satiety (how soon one feels full) • Food-related reward (hedonic pathways) • Mood, anxiety, depression, and personality characteristics. • Starvation may serve to alleviate anxiety. • Hyperactive motor behaviour. 5. Interaction with estrogens (and with age) in the brain. • Regulation of excitatory serotonin receptors. Eating Disorders

Neuropathology The Sertonergic Hypothesis In Anorexia Nervosa there is an initial increase of 5-HT: • exaggerated satiety and restricted eating behaviour and ematiation • psychotic symptoms: delusional thinking, distorted body image, exaggerated harm avoidance (i.e. repulsion of eating) Eating Disorders

Neuropathology • In recovered people with AN, there are decreased amounts of 5-HT2A receptor sites in the amygdala, hippocampus, and cingulate cortex • This decrease in 5-HT2A receptors is due to hyperserotonergic activity • May also explain reduced serotonin metabolites in the CSF Eating Disorders

Neuropathology In Bulimia Nervosa there is a general decrease in 5-HT levels: • Serotonergic pathways affects increases satiety mechanisms • Evidence of lower levels of 5-HT metabolites in Cerebral Spinal Fluid • Lower 5-HT levels promote binging due decrease in satiety mechanisms • Comorbidities between BN and other impulse control disorders (e.g. OCD, depression) • Low 5-HT levels in forebrain Eating Disorders

Eating Disorders