PSYC4080 D 6.0 Eating Disorders 1. PSYC4080 D 6.0 Eating Disorders 2 Anorexia Nervosa (AN) Self-inflicted starvation. Peaks occur between 14 and 18

PSYC4080 D 6.0PSYC4080 D 6.0 Eating DisordersEating Disorders 11

Eating DisordersEating Disorders


Anorexia Nervosa (AN)Anorexia Nervosa (AN)

Self-inflicted starvation.Self-inflicted starvation. Peaks occur between 14 and 18 years.Peaks occur between 14 and 18 years.

Average age of onset is 17.Average age of onset is 17.

Most cases develop before age 25.Most cases develop before age 25. 10% of hospitalized patients die due to 10% of hospitalized patients die due to

complications.complications.


Anorexia NervosaAnorexia Nervosa

Sharp reduction of food intake.Sharp reduction of food intake. Obsessed by the need to be thin, to avoid being Obsessed by the need to be thin, to avoid being

“fat”“fat” Recommended amount of calories for adolescent Recommended amount of calories for adolescent

girls is 1500-1800 calories/day.girls is 1500-1800 calories/day. Average daily food intake of women with AN is Average daily food intake of women with AN is

400-800 calories.400-800 calories. Very few anorexics are overweight (5%).Very few anorexics are overweight (5%). Common in women who are already considered Common in women who are already considered

slim by peers.slim by peers.


PrevalencePrevalence

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

heterosexual males.heterosexual males.


Effects on PrevalenceEffects on Prevalence

National rates are affected by social factors:National rates are affected by social factors:

1.1. Value the broadcast media places on thinness.Value the broadcast media places on thinness.

2.2. Value society places on thinness.Value society places on thinness.

3.3. More prevalent in industrialized countries.More prevalent in industrialized countries.

4.4. More common in families with a high More common in families with a high socioeconomic status.socioeconomic status.

· Very much a Very much a first worldfirst world mental disorder. mental disorder.


Case studyCase study

A 14-year old female athlete began high school at the A 14-year old female athlete began high school at the normal weight of 101 lbs. and a height of 65 inches. normal weight of 101 lbs. and a height of 65 inches.

She participated in track and basketball. Soon after She participated in track and basketball. Soon after beginning her freshman year she began to exercise beginning her freshman year she began to exercise compulsively. She also restricted her food intake. compulsively. She also restricted her food intake.

Over the course of the year her weight dropped to 93 Over the course of the year her weight dropped to 93 lbs. Her parents sought to intervene in her destructive lbs. Her parents sought to intervene in her destructive behavior. She participated in individual as well as family behavior. She participated in individual as well as family counseling. counseling.

Despite seeing a dietician her weight continued to drop Despite seeing a dietician her weight continued to drop and she soon weighed about 84 lbs. and she soon weighed about 84 lbs.


Case studyCase study

She had been hospitalized and several times doctors She had been hospitalized and several times doctors had tried nasogastric tube feedings to increase her had tried nasogastric tube feedings to increase her weight. These were unsuccessful because the patient weight. These were unsuccessful because the patient would remove the feeding tube. Her weight had fallen to would remove the feeding tube. Her weight had fallen to less then 75% of her ideal body weight. less then 75% of her ideal body weight.

By the time she was 15, the patient was referred to a By the time she was 15, the patient was referred to a psychiatrist who realized that the patient was exhibiting psychiatrist who realized that the patient was exhibiting signs of obsessive compulsive disorder. Further signs of obsessive compulsive disorder. Further counseling uncovered a history of OCD symptoms as far counseling uncovered a history of OCD symptoms as far back as the age of eight. back as the age of eight.


AN ProfileAN Profile

• Parents describe them as problem-free Parents describe them as problem-free children.children.

• Often popular, excellent students.Often popular, excellent students.• Perfectionistic, intellectually bright.Perfectionistic, intellectually bright.• Hold a negative perception of themselves.Hold a negative perception of themselves.• Inflexible, overly sensitive, emotionally Inflexible, overly sensitive, emotionally

restrained, and introverted.restrained, and introverted.• Commonly have obsessive-compulsive Commonly have obsessive-compulsive

behaviours such as ritualized cleaning or behaviours such as ritualized cleaning or cooking.cooking.

• Distorted body imageDistorted body image..


DSM-IV CriteriaDSM-IV Criteria

A. Refusal to maintain body weight at or above a A. Refusal to maintain body weight at or above a minimally normal weight for age and height minimally normal weight for age and height

e.g., weight loss leading to maintenance of body e.g., weight loss leading to maintenance of body weight less than 85% of that expected; or failure weight less than 85% of that expected; or failure to make expected weight gain during period of to make expected weight gain during period of growth, leading to body weight less than 85% of growth, leading to body weight less than 85% of that expected.that expected.



B. Intense fear of gaining weight or becoming B. Intense fear of gaining weight or becoming fat, even though they are underweight.fat, even though they are underweight.C. Disturbance in the way in which one's body C. Disturbance in the way in which one's body weight or shape is experienced, undue influence weight or shape is experienced, undue influence of body weight or shape on self-evaluation, or of body weight or shape on self-evaluation, or denial of the seriousness of the current low body denial of the seriousness of the current low body weight.weight.D. In postmenarcheal females, D. In postmenarcheal females, amenorrheaamenorrhea

the absence of at least three consecutive the absence of at least three consecutive menstrual cycles. menstrual cycles.



1.1. Restricting Type: Restricting Type: the person has not regularly the person has not regularly engaged in binge-eating or purging behaviorengaged in binge-eating or purging behavior

2.2. Binge-Eating/Purging Type:Binge-Eating/Purging Type: the person has the person has regularly engaged in binge-eating or purging regularly engaged in binge-eating or purging behavior behavior

(i.e., self-induced vomiting or the misuse of (i.e., self-induced vomiting or the misuse of laxatives, diuretics, or enemas)laxatives, diuretics, or enemas)


EtiologyEtiology

1.1. A specific environmental trigger, usually with a A specific environmental trigger, usually with a sudden onset, setting off pattern of reduced sudden onset, setting off pattern of reduced eating and obsessively exercising.eating and obsessively exercising.

2.2. Many maladadptive personality traits (obsessive-Many maladadptive personality traits (obsessive-compulsive, social phobia) compulsive, social phobia) predatepredate the onset of the onset of AN AN remain following weight normalization.remain following weight normalization.


Pathology of UndernourishmentPathology of Undernourishment

1.1. Wasting of muscle tissue occurs Wasting of muscle tissue occurs · May be uncomfortable for them to sit.May be uncomfortable for them to sit.

2.2. Immune system deficitsImmune system deficits

3.3. Poor temperature regulationPoor temperature regulation

4.4. Electrolyte imbalanceElectrolyte imbalance

5.5. Wearing down of tooth enamelWearing down of tooth enamel

6.6. Menstruation ceasesMenstruation ceases

7.7. Even after recovery, lifelong health Even after recovery, lifelong health problems occur in 80% of patientsproblems occur in 80% of patients


Bulimia Nervosa (BN)Bulimia Nervosa (BN)

1.1. Binging: ingestion of abnormally high quantities Binging: ingestion of abnormally high quantities of foodof food• 1500 – 55000 calories.1500 – 55000 calories.• May be a daily occurrenceMay be a daily occurrence

Are aware that binging is abnormal but cannot Are aware that binging is abnormal but cannot control behaviour.control behaviour.

2. Purging: vomiting, laxatives, or excessive 2. Purging: vomiting, laxatives, or excessive exercise.exercise.

May replace purging with fasting.May replace purging with fasting. Usually close to appropriate weights.Usually close to appropriate weights. Extreme guilt and concern with becoming fat.Extreme guilt and concern with becoming fat.


PrevalencePrevalence

Difficult to determine since Bulimics hide their Difficult to determine since Bulimics hide their behaviour, and since eating in public is behaviour, and since eating in public is appropriate.appropriate.

1-3% of adolescent females are affected.1-3% of adolescent females are affected. Up to 20% in college age females.Up to 20% in college age females. Peaks in early adulthood.Peaks in early adulthood. Again, less common in males.Again, less common in males. Often associated with eating problems in Often associated with eating problems in

childhood, as well as depression, early childhood childhood, as well as depression, early childhood trauma, addictions.trauma, addictions.

May be common in certain professions (dancers, May be common in certain professions (dancers, athletes, models)athletes, models)


Case StudyCase Study

““CarlaCarla’’s”s” bulimic behavior began at age 11 years after bulimic behavior began at age 11 years after many unsuccessful attempts to lose weight via caloric many unsuccessful attempts to lose weight via caloric restriction and exercise. Carla is of average height and restriction and exercise. Carla is of average height and above average weight for age. above average weight for age.

Her personal sense of body dissatisfaction was Her personal sense of body dissatisfaction was intensified several years ago by external pressure from intensified several years ago by external pressure from her school coach, peers, and family to lose weight. Carla her school coach, peers, and family to lose weight. Carla was frustrated by her dieting attempts since her caloric was frustrated by her dieting attempts since her caloric restriction resulted in food cravings and binges due to restriction resulted in food cravings and binges due to intense hunger. intense hunger.



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



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



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



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



At the same time, some of CarlaAt the same time, some of Carla’’ss girlfriends girlfriends became increasingly concerned about her became increasingly concerned about her condition. They expressed their concern about condition. They expressed their concern about Carla with the school nurse and pleaded with Carla with the school nurse and pleaded with Carla to talk with the nurse. Carla reluctantly Carla to talk with the nurse. Carla reluctantly conceded. conceded.



A. Recurrent episodes of binge eating. A. Recurrent episodes of binge eating.

(1) eating, in a discrete period of time (e.g., within any 2-(1) eating, in a discrete period of time (e.g., within any 2-hour period), an amount of food that is definitely larger hour period), an amount of food that is definitely larger than most people would eat during a similar period of than most people would eat during a similar period of time and under similar circumstancestime and under similar circumstances..

(2) a sense of lack of control over eating during the (2) a sense of lack of control over eating during the episode (e.g., a feeling that one cannot stop eating or episode (e.g., a feeling that one cannot stop eating or control what or how much one is eating)control what or how much one is eating)..



B. Recurrent inappropriate compensatory behavior in order B. Recurrent inappropriate compensatory behavior in order to prevent weight gain, such as self-induced vomiting; to prevent weight gain, such as self-induced vomiting; misuse of laxatives, diuretics, enemas, or other misuse of laxatives, diuretics, enemas, or other medications; fasting; or excessive exercise.medications; fasting; or excessive exercise.

C. The binge eating and inappropriate compensatory C. The binge eating and inappropriate compensatory behaviors both occur, on average, at least twice a week behaviors both occur, on average, at least twice a week for 3 months.for 3 months.

D. Self-evaluation is unduly influenced by body shape and D. Self-evaluation is unduly influenced by body shape and weight.weight.

E. The disturbance does not occur exclusively during E. The disturbance does not occur exclusively during episodes of Anorexia Nervosa.episodes of Anorexia Nervosa.



Purging Type:Purging Type: the person has regularly the person has regularly engaged in self-induced vomiting or the misuse engaged in self-induced vomiting or the misuse of laxatives, diuretics, or enemasof laxatives, diuretics, or enemas

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


Neuropathology in ANNeuropathology in AN

1. In AN, imaging studies show frontal and limbic dysfunction 1. In AN, imaging studies show frontal and limbic dysfunction (Herholz, 1996; Takano et al., 2001):(Herholz, 1996; Takano et al., 2001):• hypoperfusion (underactive) in the caudate and anterior hypoperfusion (underactive) in the caudate and anterior

cingulatecingulate• hyperperfusion (overactive) in hyperperfusion (overactive) in medial temporalmedial temporal and thalamic and thalamic

regionsregions

2. “Pseudoatrophy” of the brain2. “Pseudoatrophy” of the brain• Malnutrition does affect overall brain sizeMalnutrition does affect overall brain size• Reduction the size of neurons (gray matter)Reduction the size of neurons (gray matter)


NeuropathologyNeuropathology

Serotonin AbnormalitiesSerotonin Abnormalities Especially in cingulate, mesial temporal areasEspecially in cingulate, mesial temporal areas1.1. Satiety (how soon one feels full)Satiety (how soon one feels full)2.2. Food-related reward (hedonic pathways)Food-related reward (hedonic pathways)3.3. Mood, anxiety, depression, and personality Mood, anxiety, depression, and personality

characteristics.characteristics. Starvation may serve to alleviate anxiety.Starvation may serve to alleviate anxiety.

4.4. Hyperactive motor behaviour.Hyperactive motor behaviour.5. 5. Interaction with estrogens (and with age) in the Interaction with estrogens (and with age) in the

brain.brain. Regulation of excitatory serotonin receptors.Regulation of excitatory serotonin receptors.



The Sertonergic HypothesisThe Sertonergic Hypothesis

In Anorexia Nervosa there is an initial In Anorexia Nervosa there is an initial increaseincrease of 5-HT: of 5-HT:

exaggerated satiety and restricted eating exaggerated satiety and restricted eating behaviour and ematiationbehaviour and ematiation

psychotic symptoms: delusional thinking, psychotic symptoms: delusional thinking, distorted body image, exaggerated harm distorted body image, exaggerated harm avoidance (i.e. repulsion of eating)avoidance (i.e. repulsion of eating)



In recovered people with AN, there are In recovered people with AN, there are decreaseddecreased amounts of 5-HT amounts of 5-HT2A 2A receptor sites in receptor sites in the amygdala, hippocampus, and cingulate the amygdala, hippocampus, and cingulate cortexcortex

This This decreasedecrease in 5-HT2A receptors is due to in 5-HT2A receptors is due to hyperserotonergic activity hyperserotonergic activity May also explain reduced serotonin metabolites in May also explain reduced serotonin metabolites in

the CSFthe CSF



In Bulimia Nervosa there is a general In Bulimia Nervosa there is a general decreasedecrease in 5- in 5-HT levels: HT levels:

Serotonergic pathways affects increases satiety Serotonergic pathways affects increases satiety mechanisms mechanisms

Evidence of lower levels of 5-HT metabolites in Evidence of lower levels of 5-HT metabolites in Cerebral Spinal FluidCerebral Spinal Fluid

Lower 5-HT levels promote binging due decrease Lower 5-HT levels promote binging due decrease in satiety mechanisms in satiety mechanisms

Comorbidities between BN and other impulse Comorbidities between BN and other impulse control disorders (e.g. OCD, depression)control disorders (e.g. OCD, depression) Low 5-HT levels in forebrain Low 5-HT levels in forebrain

Documents

PSYC4080 D 6.0 Eating Disorders 1. PSYC4080 D 6.0 Eating Disorders 2 Anorexia Nervosa (AN) Self-inflicted starvation. Peaks occur between 14 and 18