Lecture 6: Eating disorders

What topics are discussed?

Anorexia Nervosa: DSM V criteria

1. Underweight
2. Intense fear of gaining weight
3. Disturbance in the way in which one’s body weight or shape is experienced

There are two types of AN: the restrictive type (not eating, eating very little), and binge/purging type, in which one first eats and then purges. However, these binges are not as big as in other disorders.

Bulimia Nervosa: DSM V criteria

1. Objective binge eating episodes
2. Inadequate compensatory behaviours
3. Self-evaluation is unduly influenced by body shape and weight

The main difference between BN and AN is that those with BN usually have a normal body weight.

Video
A video is shown. The woman in this video tells how eating disorders have a biological basis. Eating disorders have the highest death rate of all mental disorders and therefore it is important to pay attention to it. She explains how food plays a role in one’s thoughts and behaviours. Whereas healthy people feel calm and relaxed when eating, people with an eating disorder, e.g. AN or BN, feel high anxiety and severe disturbance when they eat.

Other specified feeding and eating disorder (OFSED)
This disorder was first called eating disorder not otherwise specified (EDNOS) in the DSM IV. In OFSED, most patients have characteristics of all ED subtypes. OFSED is the most prevalent eating disorder, as 75% of the people with an eating disorder suffer from OFSED.
It is important to note that diagnoses of eating disorders are not static. There is migration between the subtypes and there is a lot overlap. It can happen that when one has recovered from AN they later on develop signs of BN. Eating disorders like Anorexia Nervosa, Bulimia Nervosa, and Binge-Eating Disorder (BED) have over-evaluation of body weight and shape in common.

Dieting and fear of weight gain in the population
In the general population, between 21% and 66% of the women fear weight gain, a large proportion being 13 years old or 50 years or older. This is for 6-25% of men. In a study conducted about the Dutch population, 7.4% of women have been on a diet. The majority of women is somewhat afraid of gaining weight, whereas 8.9% is very afraid of gaining weight. 1.2% of men have been on a diet and the majority is not afraid of gaining weight. 1.5% is very afraid of gaining weight.

Avoidant/restrictive food intake disorder (ARFID): DSM V criteria

1. Weight loss
2. Nutritional deficiency
3. Tube feeding
4. Marked interference with psychosocial functioning

It is important to note that in ARFID there is no body image disturbance or fear of weight gain. It is about avoiding food intake. There are three types of avoidance: sensory based avoidance, arousal or interest based avoidance, and concern or fear based avoidance (being afraid that some food is e.g. poisoned).

Prevalence and comorbidity
The prevalence of eating disorders is not rising. The number of AN patients has pretty much been the same over the past few decades and the number of reported BN has dropped. There is a change in age detection. The detection at the GP for AN is mostly around 15-19 years old and there is an increase in this age category, meanwhile there is a decrease in other age categories.

(Slof-Op 'T Zand & Dingemans, 2020)

More than 70% has at least one comorbid disorder. More than half of these cases has a personality disorder. Other comorbid disorders which can occur are developmental disorders (autism, ADHD), OCD, Body Dysmorphic Disorder, affective disorders (anxiety and depressive disorders), and alcohol or substance misuse.

AN and BN
It is often thought that AN is more dangerous than BN. However, both have equal destructive consequences to the body. Here some examples are given.

• Physical consequences of underweight
  • Disturbed hormone balance
  • Infertility
  • Osteoporosis: reduced bone density
  • Poor blood circulation
  • Hypothermia
  • Fatigue, headache
  • Hair loss
  • Dry, yellow coloured skin
  • Dental problems
• Physical consequences of vomiting/taking laxatives
  
  • Loss of fluids and dehydration
  • Tooth decay/erosion
  • Acid reflux
  • Russel’s sign: scratches/scars on the back of the hand
  • Nausea
  • Dry skin
  • Dizzy spells and faintness
  • Muscle crams
  • Kidney- and liver impairment
  • Diarrhoea
  • Addiction to laxatives

Prognosis eating disorders

(Slof-Op 'T Zand & Dingemans, 2020)

Aetiology of eating disorders
The causes of eating disorders are unknown. There is not one cause. It is known that often a combination of different factors can make someone vulnerable for the development of an eating disorders. The risk factors given here are for the development of eating disorders in general, so not for AN, BN or BED specifically. Risk factors are: being female, dieting/weight concerns, body dissatisfaction, psychiatric comorbidity or negative affectivity (ED is often preceded by a depression or an anxiety disorder), negative self-evaluation, and a thin ideal.

Recovery
About 50% of the patients will recover. However, there are different definitions of ‘recovery’. For example, some consider a healthy BMI as recovery, whereas others consider a good score on a self-assessment test as recovery.

A long term follow-up study of two years examined about 900 people and their recovery of an ED. After two years, 413 people considered themselves as not recovered. 222 said they were partially recovered, and 179 said they were fully recovered. The researchers looked at ED psychopathology, psychiatric comorbidity, quality of life, and social and societal participation. A significant difference was found between these three groups in these factors. However, there was no difference in the absence of binge eating between the no recovery and partial recovery, and there was no difference in quality of life between the partially recover and fully recovery.

Many patients don’t see their disorder as a disorder. Therefore, an ED can be a part of your identity. It is important to use additional health indicators besides ED psychopathology.

Binge Eating Disorder: DSM V criteria

1. Recurrent episodes of binge eating
2. Eat least three of the following:          
   
   1. Eating much more rapidly than normal
   2. Eating until feeling uncomfortably full
   3. Eating large amounts of food when not feeling physically hungry
   4. Eating along because of embarrassment
   5. Feeling disgusted with oneself, depressed, or very guilty after overeating
3. Marked distress regarding binge eating is present
4. No inadequate compensatory behaviours

People are often not familiar with BED, including those who have it. When bingeing, people often feel like they’re not in control. There is a big difference with AN and BN: people with BED do not compensate for their food intake. People with BED can also have a normal body weight. Bingeing is often done because it can help those people deal with stress or depressive moods. However, they often feel guilty or gross afterwards.

BED is often associated with obesity. The prevalence of BED is between 1 and 3% in the general population. The percentage of BED is high in individuals seeking weight loss treatment (30%). Obesity definitely plays a role in the development and maintenance of binge eating. However, BED has a more severe psychopathology and it comes with a lower self-esteem and more severe depressive symptoms. BED has more comorbid psychiatric axis I and II disorders. in BED there are more concerns about shape and weight and how you evaluate yourself. People with BED often have a negative body image.

Also, BED shows less severe eating disorder psychopathology than BN, and BED appears to be a discrete ED category as there is less overlap.

Emotion regulation
Most models and theories about ED incorporate mood intolerance as a maintenance factor. In other words, this means the inability to regulate emotions and depressive feelings. These include negative emotions like depression/sadness, anxiety, and anger/frustration, but also positive feelings like excitement. In BED, depression/sadness and anger/frustration are most prominent. People with BED often report interpersonal experiences, like anger, disappointment, and feelings of being hurt or lonely.

Binge eating in BED
In the onset of BN, people often start with dieting. The onset of binge eating seems to precede the onset of dieting after they have binged. There is a link between negative mood states and binge eating without restrictive eating. Emotional disturbances and coping deficits increase binge eating. Binge eating is for people with BED often seen as an ‘escape for awareness’:

• • Escaping from negative mood
  • Alleviates emotional stress
  • Attention is drawn away from emotional distress
  • Narrowing the focus to the immediate environment (food)
  • Feeling numb while bingeing
  • Chewing helps me to forget
  • Loss of control over eating
    
    • “I have no choice”
  • The only thing on their mind is food
  • “I deserve something nice”

Experimental studies
Aims of experimental studies are to figure out what the underlying mechanisms are for binge eating, identifying the role of emotions in the maintenance of binge eating, and figuring out what the causal relationship is between negative emotions and binge eating. Conclusions drawn from these experimental studies show that a negative mood increases loss of control over eating. Acute negative moods lead to binge eating rather than a stable negative mood, and one will take a higher caloric intake after negative mood induction. Thus, more depressive symptoms lead to more consumption of calories, and more changes in negative mood lead to more consumption of calories in severely depressed people. For these, overeating may serve as a means to (temporary) repair one’s negative mood. Depressed individuals with BED are less able to cope with negative moods. Difficulties in emotion regulation can lead to binge eating when effective skills are not available.

Ecological Momentary Assessment (EMA)
In EMA studies, questions are asked several times a day as it is a repeated measures within one person. This can either be fixed sampling (measuring on specific moments a day), event sampling (recording when specific behaviours occur), or random sampling (random within a specific time period, e.g. 2 hours). There is a report on symptoms, affect, behaviour, social activities and cognitions. Temporal things are recorded, like feelings while in the moment itself. EMA studies conducted about BED have shown that negative emotions can lead to binge eating.

Overall conclusions that can be drawn from both experimental studies and EMA studies show that overeating/binge eating may serve as a means to repair one’s negative mood and to regulate negative emotions. It is in line with the escape model: binge eating to escape from negative mood and to alleviate emotional stress. There is a link between depressive symptoms and binge eating. Severe depressive symptoms worsen the ability to handle negative mood states which in turn increased the urge to binge.

Treatment BED
Outpatient Cognitive Behavioural Therapy is often the first choice and it is appropriate if followed by weight loss treatment. This is semi-structured and problem-oriented, and it consists of 20 sessions. The first phase entails 10 sessions, in which the focus is on the development of regular eating pattern, learning how to resist binge eating, and identifying and correcting dysfunctional cognitions. Two sessions are with a dietician.
The second phase consists of 8 sessions. The focus is on underlying problems, self-esteem, stress-management, problem solving, and weight loss issues. Here too are two sessions with a dietician.
The third phase consists of two sessions. The focus is on a relapse prevention plan, writing down several risk factors for a relapse, making a plan how to avoid these risk factors, what are the first small signals, thinking of actions after first signals, and being aware of high risk foods.

About 70% of the patients with BED is abstinent of binge eating after CBT treatment. Some, however, need extra treatment, for example for comorbid psychiatric disorders.

Treatment can be supplemented by anti-depressants. Yet there are  lot of self-help programs based on CBT too. Treatment usually consists of a multidisciplinary team, including a psychologist, psychiatric nurse, dietician and a physical therapist.

The start group starts with six sessions and it is an open group. It consists of psycho-education, enhancement of motivation, engaging family, and formulating therapy goals. A dietician and a physical therapist are often present too.

What topics are discussed which aren’t discussed in the literature?
The topics about AN, BN, and other eating disorders are not discussed the literature. The literature mainly covers BED. Also, the topics about EMA and experimental studies are not discussed in the literature.

How has this topic developed over the past few years?
The DSM has made some changes in the transition from DSM IV to DSM V. Some disorders, like EDNOS, have changed their names and their criteria. The prevalence of anorexia nervosa has pretty much stayed the same, but the prevalence of bulimia nervosa has increased over the past decades.

What comments are made with regard to the exam?

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What questions are being asked which could be asked on the exam? What is the answer?

How can we study the relation between binge eating and mood/depressive symptoms?
This can be done by doing experimental studies or EMA studies. In EMA studies, questions are asked several times a day as it is a repeated measures within one person. This can either be fixed sampling (measuring on specific moments a day), event sampling (recording when specific behaviours occur), or random sampling (random within a specific time period, e.g. 2 hours). There is a report on symptoms, affect, behaviour, social activities and cognitions.