Transcript Psychological Aspects of Anorexia Nervosa and binge Eating

Psychological Aspects of
Eating Disorders
Sally Schwab, Ph.D., MSW
Director, Primary Care Faculty
Development and Curriculum
New York Medical College
Eating Disorders
 Affect between 5 to 10 million people
in the US
 Approximately 5 -10% of people with
eating disorders will die
 Untreated, 18 -20% of people with AN
will die within 20 years
 ED’s have one of the highest mortality
rates of any psychiatric illness
 Disorders of control not food
Pediatric Eating Disorders
 Have been largely ignored
 Pts with AN and BN often become
symptomatic in childhood &
adolescence
 Largest increase in ED’s seen in
minorities, children and males
 AN third most common chronic illness
in adols after obesity & asthma
Infancy
 Difficulties in feeding
 Failure to thrive
• physical abnormalities
• developmental delay (cognitive or
genetic disorders)
• parental mental illness
• temperamental mismatch
Toddlers
 Transition between parental feeding
and self -feeding
• continuum of normal, picky and
anorectic eaters
• separation issues
• anorectic toddlers have higher
temperament ratings on difficulty,
irregularity, negativity, dependence
• These mothers have greater attachment
insecurity
School-Aged Children
 Kids compare themselves to others
 AN can develop in childhood
 BN usually develops after puberty
 Pica in childhood related to BN
 Picky eating related more to AN
 Can see excess exercise, talk of
dieting and desire to be thin and
beautiful.
School-aged
 Boys and girls 7 - 11 rate obese
children as;
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having fewer friends
being less liked by parents,
doing less well at school
being lazier
being less happy
being less attractive
School-aged
 Gender differences emerge between
8-10
 Body dissatisfaction, esp. for girls,
becomes more pronounced with age
 1989 CDC study: desire to be thinner
increased from 40% in grade 3 to 79%
in grade 6
Role of parents
 Parent’s concerns about own weight
affect boys and girls
 Maternal and paternal overeating,
body dissatisfaction and bulimic
symptoms predicted secretive eating
in children
 Maternal /paternal dieting and
behavior predicted overeating in
children
Anorexia Nervosa (AN) and Bulimia
Nervosa (BN)
 Inability to distinguish physiological
sensations of hunger and fullness
from emotional feelings
 View body as something to be
controlled by the mind
• I feel fat, therefore I am worthless
• I feel thin, therefore I am good
DSM-PC/DSM-IV criteria for AN:
Dieting/Body Image Variation
 Dieting may occur if child is
overweight, but be realistic
 Does not completely eliminate any
food group, but decreases food intake
 Child favors thin appearance but has
realistic image
 Child can stop dieting voluntarily
DSM-PC/DSM-IV criteria for AN:
Dieting/body image problem
 Dieting is more restrictive & results in
weight loss during growth periods
 Person starts to become obsessed
with pursuit of thinness and has fears
of gaining weight
 Begins to develop a consistent
disturbance in body perception and
starts to deny weight loss is a
problem
Anorexia Nervosa (DSM IV)
 Refusal to maintain body weight at or
above minimally normal weight
 Body weight <85% of that expected
 Intense fear of weight gain, becoming
fat , even though underweight
 Disturbance in way weight is
experienced
Anorexia Nervosa (DSM IV)
 Denial of the seriousness of low body
weight
 Undue influence of body weight on
self-evaluation
 Absence of at least 3 consecutive
menstrual cycles
• Restricting type: no regular binge /purge
• Bingeing/purge type: regular
binge/purge
Clinical Red Flags: AN
 Ritualistic eating habits, such as
cutting up meat in very small bites
 Refusal to eat in front of others
 Suddenly deciding to become a
vegetarian, or eating low / no-fat
foods
 Continual exercising
 Hypersensitivity to cold
 Wearing layers of clothes
DSM-PC/DSM-IV criteria:
Purging/Binge Eating- variation
 Occasional overeating or perception
of overeating, either objective
/subjective binges occurs.
 Intermittent concern about body
image or getting fat when too much
food is eaten. Not pervasive, doesn’t
change eating patterns
 Normal weight gain is present
DSM-PC/DSM-IV criteria:
Purging/ Binge-Eating problem
 Experimentation with vomiting,
laxatives, fasting, or exercise to
prevent weight gain
 Isolated episodes far apart in time
 Increased episodes of uncontrolled
eating & perception of body becomes
more distorted
 Not sufficient to qualify for bulimia
Bulimia Nervosa (DSM - IV)
 Recurrent episodes of binge eating:
• Eating, in a discrete period of time (e.g.
within 2 hr period), an amount of food
that is definitely larger than most people
would eat during that time
• Sense of lack of control over eating
during the episode (feeling like one can
not stop eating or control what or how
much one is eating
Bulimia Nervosa (DSM - IV)
 Recurrent inappropriate
compensatory behavior to prevent
weight gain:
• self-induced vomiting
• misuse of laxatives, diuretics, enemas or
other medications; fasting, excessive
exercise
• Binge /purge occurs, on average 2 x
week for 3 months
Bulimia Nervosa (DSM - IV)
 Self-evaluation is unduly influenced
by body shape and weight
 Does not occur exclusively during
episodes of anorexia nervosa
• Purging type
• Non-purging type
Clinical Red Flags: BN
Normal-weight adolescents often make
excuses to go to the bathroom after meals
 Mood swings
 Buying large amount of food, which
suddenly disappear (hoarding)
 Unusual swelling around jaw
 Eating large amounts of food on spur of
moment
 Laxatives or diuretic wrappers found in
trash
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Binge Eating Disorder
(BED)
 Patients binge but do NOT purge
• 2 x week for 6 months
 Frequent failed attempts at dieting
 Eat alone due to embarrassment
about weight/restricts activities due
to shame
 Often overweight
 Feels tormented by eating habits
 Failures attributed to weight
Characteristics of ED
Patients
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Severe disturbances in
eating behavior
Intense fear of being fat
Distorted thinking
Disturbance in perception
of shape
Self-esteem highly
dependent on weight
Control of food = control of
world
Way to manage anxiety;
rigid and ritualistic
Secretive
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Weight gain = “bad”, no
control
Weight loss = “good”, in
control; measure of
achievement
As weight decreases,
concern about weight
increases
Collect recipes/ cook for
others
Obsessively weigh
themselves; exercise
Distorted thinking
Filtering: magnify the negative
 Polarization: Things are good or bad
 Expecting disaster
 Personalization
 Over generalizing
 Control fallacies: you feel externally
controlled
 Shoulds: iron clad rules about how to act
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Personality features
AN
BN
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perfectionist
high achievers
intense neediness
emotionally inhibited
need for control
feel ineffective
lack of insight
fear maturity/
struggle for autonomy
fear separation
sexuality
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self-regulatory
problems with anxiety
social discomfort
sensitivity to
reflection / self
critical
high academic
expectations
self-mutilation
impulsive behaviors
• shop lifting,
promiscuity
Gender Differences
Girls
Boys
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Between 50-69%
normal weight
dissatisfied
16% underweight
want to be thinner
Parents focus on
physical appearance
Decreased body
satisfaction after
puberty
Dislike of thighs,
buttocks, stomach
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21% think they are
underweight
10% think overweight
Parents focus on
physical functioning
Increased body
satisfaction after
puberty
Desire to be bigger
and taller
Gender differences
 Girls tend to use more social
comparisons which increase body
dissatisfaction and dieting behaviors
 Boys are less influenced by sociocultural pressures than girls
 Girls tend to describe themselves
more negatively
Gender differences
Physical attractiveness often predicts selfconcept and self-esteem in girls
 Physical effectiveness predicts selfconcept in boys (strength, sports)
 When girls are praised for attractiveness,
they begin to overvalue their physical
attributes and invest more self-worth in
matters related to appearance
 Physically attractive girls are more
preoccupied with weight (beauty =curse)
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Factors Affecting Body Image
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Sociocultural
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Gender
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Puberty
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Ethnicity
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SES status
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2oth century ideal is
“thin and light”
Intense focus on
physical appearance of
girls
Associated with
increased body weight
and fat
Subcultural differences
Desire for thinness
correlated with higher
ses
Cultural Issues
Western ideal =
thin
 Non-Western
cultures - obesity
is often admired
 Women believe
they are more
attractive to men if
thin
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NOT substantiated by
men
 Studies show men’s
stated preference of
female weight was
significantly greater
than the women’s
assessment of
selves
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Ethnic Differences
African American girls seem more satisfied
with weight; prefer heavier ideal.
 African American girls more affected by
mothers’ influence, whereas whites more
affected by peers.
 Binge eating more frequent in Asians and
less frequent in blacks.
 Hispanics reported more use of laxatives
and diuretics to lose weight
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Epidemiology
More than 50% of
women in U.S. diet
 15% of all women
medical students
have lifelong hx of ED
 > 90% are women
 > 95% are white
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> 75% are
adolescents when
first dx
 2/3 of high school
students report
being on a diet
when only 20%
were overweight
 Most from mid upper SES
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Epidemiology
 Third most common chronic illness
in adolescent women is AN
 Mortality is reported to be about 6%
 1997 Youth Risk Behavior Study by
CDC reports:
• 30% of high school students are dieting
• 4.9% use diet pills
• 4.5% induced vomiting or use laxatives
Prevalence in Males
Of AN patients, 5% - 10% are men
 One study of Navy men reports 2.5%
prevalence of AN, 6.8% of BN and 40% of
binge eating
 A study of civilian men report of those with
ED , 42% are homosexual or bisexual while
58% with AN are asexual
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Epidemiology
 Occurs in .5% - 3% of all teenagers
 Prevalence in U.S. of AN is .5% - 1%
 1/3 of insulin dependent females with
diabetes suffer from an ED
 Peak onset of AN:
• 13 -14 : puberty
• and 17 -18: leaving home / identity
formation
Prevalence of bulimia
 Up to 25% of adolescents have at
some time engaged in purging to
control weight
 Between 4% - 10% of older
adolescents and college age women
develop BN
 Mean age of onset: 18.4 years of age
• peak of sexual maturity and body image
dissatisfaction.
Who may be at risk?
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Physically active people: competitive athletes:
skaters, gymnasts, dancers, runners
• 15%-60% estimated prevalence
Male wrestlers and rowers
• 1/3 of high school wrestlers use method of
“weight-cutting”: food restriction, fluid
depletion using steam rooms, saunas, diuretics
(often resume normal eating off season but
maintain up to only 3% body fat)
Female Athlete
 Female athlete triad
• Menstrual dysfunction
• Eating disorders
• Osteoporosis
At risk...
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Higher incidence for men and women in military
Greater risk for girls who undergo early puberty
Patients with a family history of ED
Vegetarians among adolescents:
• twice as likely to diet frequently
• four times as likely to intensively diet
• eight times as likely to use laxatives as their
non-vegetarian peers
Body Image Disturbance
 Body image disturbance gets WORSE
with weight loss
 As the typical teenage girl loses
weight, she becomes more satisfied
 As teenage girl developing AN loses
weight, she becomes less satisfied
and resets her initial goal
Body Image
 The way one experiences one’s body
 Girls who have greater self-confidence
and positive self-esteem more likely to
have secure, healthy body image
 Two basic dimensions
• Body satisfaction
• Body size perception
Body Satisfaction
(Affective)
How a person feels
and acts about
their size and
appearance
 Personal meaning
and feeling are
associated with the
body
 I’m inferior
because I’m fat
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Body Size Perception
(Cognitive)
Estimation of one’s
size, but also
distorted perception
that the body is far
from the idealized
standard
 The way one sees
themselves and the
way they think
others see them
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Displacement of Feelings
 I am depressed and I really feel fat
 No boy asked me out because I am fat
 Bad things happen to me because I am
fat
 Goal: separate body image issues
from other emotional aspects of one’s
life
 Correlation between weight loss and
happiness is illusory
Dangers for Future
 Never learn how to cope with real
issues
 Will always blame body when
relationships fail
 Unrealistic expectations get set up
 Always tries hard to please others;
overlook own needs
Precipitating Factors
 dieting prompted by plumpness
 being teased about weight
 depression
or seasonal onset
 feeling lack of control in one’s life
 interpersonal conflict /first sexual
experience
 developmental tasks of transition
 separations
Inadequate coping skills in
response to:
 Puberty
 separation - leaving home to college
 stress
 pressure for high achievement
 regulation of tension / anxiety
 sexual trauma
Characteristics of a binge
 ingestion of between 5,000 - 20,000
calories per episode (within 2 hours)
 continual snacking on small amounts
during day is NOT a binge
 food often is high caloric and carbos
 usually occurs in secret
 continues until uncomfortably full, is
interrupted or run out of food
Bingeing and Purging
 80-90% of bulimics induce vomiting
 vomiting often a goal in itself
 induce with fingers or instruments
• first eat “marker” food, so when purge
will know all is gone
 develop ability to vomit at will
 could use up to 100
laxatives/diuretics per day
Binges triggered by:
 dysphoric mood states
 interpersonal stressors
 intense hunger following dietary
restraint
 negative feelings related to weight
During a Binge...
 Feel lack of control
 In a dissociative state
 Feeling of “frenzied”
 Feeling of relief
 Average binge/purge episodes - 14
times a week
 Most don’t want to give it up
Goals of Purge
prevent weight
gain
 feel in control
 feel relief from
physical
discomfort
 reduce fear of
gaining weight
 purge bad feelings
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Effects of purge
reduce dysphoria
 reduce anxiety
 eradicate fear of
weight gain
 disparaging selfcriticism
 depressed mood
 guilt /shame
 exhaustion

Associated Mental Disorders
AN
BN
50% -75% depression
 up to 69% have OCD
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43% anxiety
disorders
 49% substance abuse
 12% bipolar
 40% personality
disorders
 20%-50% history of
sexual abuse
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State of Starvation
 depressed mood ; poor concentration
 social withdrawal / apathy
 decreased ability to make decisions
 irritability/ insomnia
 decreased libido
 food obsessionality
• hoarding; preoccupation; abnormal
tastes
Theories of Etiology
Problems in separation / autonomy; control
 Conflicts in sexuality
 History of sexual abuse
 Family conflicts (over involved parent in AN
/ detached parent in BN)
 Family and personal hx of depression
 In BN more likely to have obese parent
 Neurotransmitter imbalances
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Family Influences
Dysfunctional families create vulnerable
individuals - look at content of what is
expressed as link to symptom
 ED families have the following:
• concern for weight/ shape/ appearances
• concern for achievement/ reputation
• need to modulate depressive affect
• low self-esteem
• difficulty with impulse regulation
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Prognosis
 30% of pts with AN will be chronically
ill
 After RX, 50% continue with
persistent social impairment and
50% will relapse
 10% will die of the illness
Prognostic indicators
Good
Bad
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pt admits to feeling
hungry
positive self-esteem
mature
developmentally
has attained some
autonomy
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Being ill >6 yrs
premorbid obesity
bulimic behavior
unstable personality
excessive somatic
concerns
lower minimum
weight
ambivalence to
recovery
Issues leading to rx problems
Patient
Clinician
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Denial of illness
Shame for BN and
secretiveness
pathologic pursuit of
thinness
Inability to trust adults
co-morbid disorders
nutritional chaos
substance abuse
distorted thinking
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Pt evokes intense feelings
of hostility; helplessness
and stress
lack of experience
increases frustration
more experience gives
long term perspective
Female clinicians may
evoke jealousy
Hard to hear about details
of purge - lead to revulsion
Treatment difficulties
 Patients don’t want to get well
 Denial of symptoms
 Pts fear you want to make them fat
 Fear dependency
 Rejection sensitivity
Assessment of Body Image
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Is there anything about your body that you wish you
could change?
How important is your body size to how you feel
about yourself as a person?
Do you spend a lot of time thinking about your
body?
Are there things you intentionally avoid because of
the way you feel about your body?
Do you try to do something about your weight? Are
you trying now?
What are you doing to control your weight?
Screening for ED’s
 How do you feel about exercise?
• Avoids humiliation if pt doesn’t exercise
• Lets you understand why person
exercises
 If I walked into your house, what kinds of
foods would I find?
 What would you like to have in your house,
but don’t have?
 Are there any restrictions on what you eat?
Strategies
Be open, honest, firm; non-judgmental
 Set realistic goals
 Attempt to build trust
 Be sensitive to the shame and humiliation
the patient feels
 Understand the intensity of the denial and
ambivalence to recovery
 Depersonalize pts poor compliance
 Appreciate pt’s mistrust of doctors
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Strategies
Do not insist on rapid weight gain and
threaten hospitalization - will lead to binge
eating to meet goal then purge
 Beware of refeeding syndrome
 Weigh pts when completely disrobed and
after empty bladder
• pts wear layers of clothing to add weight
• pts load up on water before being
weighed
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 DO NOT TREAT ALONE
Treatment modalities
 Inpatient Vs outpatient
 Medication
 Nutritional counseling
 Group or family therapy
 Psychoeducational approach
 Individual psychotherapy
• cognitive / behavioral/ psychodynamic
Cognitive Behavioral Therapy
 Best proven approach to ED
 Focus on restructuring “thinking
errors”
 Focus on present not past
 Help pt to recognize the distorted
reactions to food
 Discovers false attitudes / become
less self-critical
Goals of Treatment
 Short term
• Nutritional rehabilitation: restore
healthy weight; medically stable state
• Restore to non-suicidal state
 Long Term
• Restore to “normal eating” pattern
• Dx and treat long term social, psych and
behav. Problems
• Restructure dysfunctional thinking