Hovedoppgave psykologi - Nerv¸se spiseforstyrrelser og komorbiditet

  • View

  • Download

Embed Size (px)


The goal of this project was to investigate what kind of co-morbid psychiatric disorders that mostly occur in relation to Bulimia Nervosa and Anorexia Nervosa (also known as the nervous eating disorders). This project presents a range of empirical studies conducted within this field and tries to unveil if there are any clear patterns that can be seen throughout these studies. The results of the different studies are found to vary a lot and several different conclusions are drawn to what co-morbid psychopathology one can find related to the nervous eating disorders, making it difficult to reach conclusions within this field. However, there are some psychiatric disorders that there seem to be found in almost all of the empirical studies that are presented. These are unipolar depressive disorders, two forms of anixiety disorders – namely Obsessive-compulsive disorder and Post-traumatic stress disorder, Substance abuse disorder and Borderline personality disorder. Unipolar depressive disorders are seen in correspondence with both Anorexia Nervosa and Bulimia Nervosa. This is also the case for Obsessive-compulsive disorder, although it occurs somewhat more often in people diagnosed with Anorexia Nervosa. Post-traumatic Stress Disorder is seen to occur in relation to Bulimia Nervosa, and Substance abuse disorder is also shown to be present more often in people with this disorder, than in those diagnosed with Anorexia Nervosa. For the Axis II disorders from the DSM-IV clinical diagnostics system, only Borderline personality disorder is seen as a co-morbid psychiatric disorder to nervous eating disorders, namely in relation to Bulimia Nervosa. In this notion it should however be noted that numbers from the different studies vary significantly, and that Obsessive-Compulsive personality disorder as well as other affective personality disorders in some studies are seen as occurring co-morbid with the nervous eating disorders. No conclusion can be made however, due to the disagreement between the different empirical sources.Next, the project looks at the findings from the empirical studies in light of Attachment Theory and Theory of Mentalization. A model for the emergence of psychopathology is proposed and the different findings are explained in relation to this model. Dysfunctional early attachment is seen as a factor for the inhibition of normal development of the mentalization-capacity, which in turn leads to dysfunctional affect-regulation. This is seen as a basis for the development of the nervous eating-disorders and the majority of the co-morbid psychiatric disorders. An alternative explanation for the co-morbidity of depression and substance abuse is also presented, arguing that these disorders may rather be looked upon as a result of the distress caused by the presence of an eating disorder.

Text of Hovedoppgave psykologi - Nerv¸se spiseforstyrrelser og komorbiditet

Nervse spiseforstyrrelser og komorbiditetSpecialeoppgave i PsykologiEivind Mlmen, CPR-nr: 080782-305110. Semester Psykologi, KANUK

Aalborg Universitet

28. mai 2009____________________________________________

Oppgavens samlede antall tegn med mellomrom: 106.790Tilsvarende flgende antall normalsider: 44,5INNHOLDSFORTEGNELSE









92.5Kritikkpunkter og begrensninger


103.1Blinder, Cumella & Santharas kartlegging

113.2Hudson, Hiripi, Pope & Kesslers underskelse

133.3Angstlidelser andre underskelser

153.4Depressive lidelser andre underskelser

163.5Rusmisbruk andre underskelser

173.6 Personlighetsforstyrrelser

173.6.1Kristine Godt sin underskelse

183.6.2Sansone, Levitt & Sansone sin samleunderskelse



213.7.1Depressive lidelser





234.1Bowlbys tilknytningsteori

244.1.1Viktigheten av emosjonelle bnd og tilknytningens styringssystem

254.1.2Foreldrenes innvirkning p barnets utvikling

294.1.3Stier i personlighetsutviklingen

304.2Mentalisering et neuro-psykodynamisk perspektiv

304.2.1Genetisk grunnlag

314.2.2Utviklingen av evnen til mentalisering, affektregulering og selvet

344.2.3Mentaliseringsevnens rolle i psykopatologi


385.1 Borderline personlighetsforstyrrelse og bulimia nervosa

385.1.1Mentalisering, tilknytning og borderline personlighetsforstyrrelse

405.1.2Mentalisering, tilknytning og bulimia nervosa


415.2Angstlidelser og nervse spiseforstyrrelser

415.2.1OCD og nervse spiseforstyrrelser

425.2.2PTSD og bulimia nervosa

435.3Depressive lidelser, rusmisbruk og nervse spiseforstyrrelser

445.3.1Depressive lidelser og nervse spiseforstyrrelser

445.3.2Rusmisbruk og nervse spiseforstyrrelser



476.1Komorbide lidelser i forbindelse med nervse spiseforstyrrelser

476.2Teorigrunnlagets forklaringsmodell



Komorbiditet er et utbredt problemomrde i forhold til en rekke psykiske lidelser. Mest kjent er kanskje forholdet mellom rusmisbruk og psykiske lidelser, der en i Norge ser at omkring to av fem pasienter som er innlagt ved de akutte psykiatriske avdelingene har narkotika- eller alkoholproblemer, og rusproblematikk i sammenheng med psykiske sykdommer omtales som en av de strste utfordringene det psykiatriske helsevesenet str ovenfor i dag. (Akerholt, 2006, pp. 222, 224f) Dog er ikke rusmisbruk alene om opptre som tilleggsdiagnose, og ofte finner man at en person diagnostisert med n psykisk lidelse ogs oppfyller kriteriene for en eller flere andre. I forhold til behandlingen av psykiske lidelser pner dette ndvendigvis for noen problemstillinger.Samtidig ser man at spiseforstyrrelser blir stadig mer utbredt, ikke bare i hyppighet, men ogs i forhold til hvilke grupper som rammes. Stereotypen om tenringsjentene som sulter seg for bli modeller er ved falle fra hverandre. Man ser at stadig yngre personer rammes, at flere gutter diagnostiseres, og man har ftt et kt fokus p at personer ogs innenfor idrettsmiljene er utsatt for lidelsene. Sledes representerer ogs spiseforstyrrelsene tydeligvis en kende utfordring for det psykiatriske helsevesenet.

Underskelser og erfaringer fra klinisk arbeid med spiseforstyrrelser viser videre at komorbiditet ogs er en aktuell problemstilling i forhold til disse lidelsene. Flere tekster og underskelser redegjr for forekomsten av komorbide lidelser i sammenheng med bulimia og anorexia nervosa. P sin side finnes det ogs en rekke forklaringsmodeller som belyser hvordan spiseforstyrrelser og andre psykiske lidelser oppstr. Denne oppgaven nsker holde problemstillingen komorbiditet og nervse spiseforstyrrelser opp mot hverandre. Hvilke psykiske lidelser er det som hyppigst opptrer i forbindelse med anorexia og bulimia nervosa? Videre vil oppgaven underske om man i noen av de ulike forklaringsmodellene kan finne trder som binder de nervse spiseforstyrrelsene og de komorbide lidelsene sammen, og som kan gi mulige forklaringer p hvorfor disse lidelsene opptrer i sammenheng.1.1Problemformulering

Hvilke komorbide psykiske lidelser finner man hyppigst hos personer med nervse spiseforstyrrelser?

Hvordan kan man, med grunnlag i utviklingspsykologisk teori, forklare at disse lidelsene opptrer i sammenheng med nervse spiseforstyrrelser?1.2BegrepsavklaringAnorexia nervosa: DSM-IV (1994, 307.1) definerer lidelsen som:

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).

B. Intense fear of gaining weight or becoming fat, even though 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, i.e., the absence of at least three consecutive menstrual cycles. (A woman is considered to have amenorrhea if her periods occur only following hormone, e.g., estrogen, administration.)


Restricting Type:during the current episode of Anorexia Nervosa, the person has not regularly engaged in binge-eating or purging behavior (i.e., self-induced vomiting or the misuse of laxatives, diuretics, or enemas)

Binge-Eating/Purging Type:during the current episode of Anorexia Nervosa, the person has regularly engaged in binge-eating or purging behavior (i.e., self-induced vomiting or the misuse of laxatives, diuretics, or enemas)ICD-10 (2007, F50.0) har flgende definisjon:

A disorder characterized by deliberate weight loss, induced and sustained by the patient. It occurs most commonly in adolescent girls and young women, but adolescent boys and young men may also be affected, as may children approaching puberty and older women up to the menopause. The disorder is associated with a specific psychopathology whereby a dread of fatness and flabbiness of body contour persists as an intrusive overvalued idea, and the patients impose a low weight threshold on themselves. There is usually undernutrition of varying severity with secondary endocrine and metabolic changes and disturbances of bodily function. The symptoms include restricted dietary choice, excessive exercise, induced vomiting and purgation, and use of appetite suppressants and diuretics.Bulimia nervosa:DSM-IV (1994, 307.51) har flgende definisjon p lidelsen:A. Recurrent episodes of binge eating. An episode of binge eating is characterized by both of the following:

(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)

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 ofAnorexia Nervosa.


Purging Type:during the current episode of Bulimia Nervosa, the person has regularly engaged in self-induced vomiting or the misuse of laxatives, diuretics, or enemas.Non-purging Type:during the current episode of Bulimia Nervosa, 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.

ICD-10 (ibid., F50.2) definerer lidelsen som:A syndrome characterized by repeated bouts of overeating and an excessive preoccupation with the control of body weight, leading to a pattern of overeating followed by vomiting or use of purgatives. This disorder shares many psychological features with anorexia nervosa, including an over-concern with body shape and weight. Repeated vomiting is likely to give rise to disturbances of body electrolytes and physical complications. There is often, but not always, a history of an earlier episode of anorexia nervosa, the interval ranging from a few months to several years.Borderline personlighetsforstyrrelse:

DSM-IV (1994, 301.83) definerer lidelsen som:

A pervasive pattern of instability of interpersonal relationships, self-image, andaffects, and marked impulsivity beginning by early adulthood and present in a variety of contexts, as indicated by five (or more) of the following:

(1) frantic efforts to avoid real or imagined abandonment.

(2) a pattern of unstable and intense interpersonal relationships characterized by alternating between extremes of idealization and devaluation.

(3) identity disturbance: markedly and persistently unstable self-image or se