CHAPTER 9 (EATING DISORDERS & OBESITY) CLINICAL ASPECTS OF EATING DISORDERS Age of onset & gender differences Anorexia

Nervosa and bulimia nervosa are often considered modern disorders , yet pathological patterns of eating date back several centuries. It was not until 1970s and 1980s, however, that eating disorders began to attract a great deal of attention. Neither anorexia nervosa nor bulimia nervosa occurs in appreciable numbers before adolescence, although children as young as 7 have been known to develop eating disorders, especially anorexia nervosa. The incidence of eating disorders seems to decline after about age 25, although good epidemiological data on this point are lacking. Anorexia Nervosa literally means lack of appetite induced by nervousness - Fear of gaining weight or being fat. - Within DSM-IV- TR, it is coupled with the refusal to maintain that is normal for the persons age and height. - Distorted perception of body shape and size. 2 types of Anorexia Nervosa The restricting type- every effort is made to limit how much food is eaten, & calorie intake is totally controlled. Patients tend to avoid eating in the presence of other people. When they are at the table, they may eat excessively slowly, cut their food into very small pieces & dispose food secretly.

Binge eating/purging type have breakdown of restraint that results in periods of binge eating.

(Binge- involves the out-of-control eating amounts of food that are far greater that what most people would eat in the same amount time and under the circumstances.) These binges are followed by the urges to purge. Methods of purging commonly include self- induced vomiting, misuse of laxatives, diuretics & enemas.

Bulimia Nervosa the word bulimia came from the Greek bous which means ox and limos or hunger. The difference between a person with bulimia nervosa and a person with the binge-purging type of anorexia nervosa is weight. By definition, the person with anorexia nervosa is severely underweight. This is not true of the person with bulimia nervosa. The typical patient with anorexia nervosa engages in much denial regarding the seriousness of her disorder & may remain seemingly unaware of the shock& concern w/ which others view her emaciated condition. In contrast, the mindset of the average bulimia nervosa patient is anything but complacent. Preoccupied w/ shame, guilt, self-deprecation, & efforts of concealment, she struggles painfully & often unsuccessfully on a daily basis to master the impulse of binge. Medical complications of Anorexia Nervosa & Bulimia Nervosa Anorexia Nervosa is one of the most lethal psychiatric disorders there is. Not surprisingly, many patients w/ this disorder look extremely unwell. - Hair on the scalp thins & becomes brittle, as do nails. - The skin becomes very dry & downy hair (called lanugo) starts to grow on the face, neck, arms, back & legs. - Many patients also develop a yellowish tinge on their skin, especially on the palms of their hands. - Because they are so undernourished, people w/ this disorder have a difficult time dealing with colds. - Hands and feet are often cold to the touch & have a purplish blue tinge due to problems w/ temperature regulation & lack of oxygen to the extremities. - As a consequence of chronically low blood pressure, patients often feel tired, weak, dizzy, & faint. - Sudden death from heart arrhythmia (irregular heartbeats) can occur w/ anorexia nervosa. - Damage to the heart muscles caused by using ipecac to induce vomiting. - Damaged teeth due to throwing up repeatedly by acids of the stomach - Mouth ulcers and dental cavities - Swollen parotid (salivary) glands due to vomiting.

Other forms of eating disorders Eating disorder not otherwise specified (EDNOS) This diagnostic is given to approximately one-third of all patients who seek treatment for an eating disorder. The majority of conditions that fall under this diagnosis are atypical clinical variants that resemble anorexia nervosa or bulimia nervosa (or both). Binge-eating disorder (BED) this new diagnosis is currently not part of the formal DSM. Instead its listed in an appendix reserved for diagnostic conditions that warrant further study. Binge-eating disorder is proposed as a separate disorder distinct from bulimia nervosa and nonpurging type. The difference is that the individual w/ BED binge at level comparable to a patient w/ bulimia but does not regularly engage in any form of inappropriate compensatory behavior such as purging, using laxatives, or even exercise. Distinguishing among diagnoses As is perhaps implied by the large proportions of eating disordered patients who fall within the EDNOS category, the diagnosis of an eating disorder is not always clear- cut. The distinction between normal and disordered eating, particularly in a time when very large numbers of young women perceive themselves as overweight & therefore indulge in one or another form of dieting, is at best a fuzzy one. The distinction between anorexia nervosa & bulimia nervosa is often less than clear, & whether the two disorders should be separated at all has been seriously debated. Comorbidity of eating disorders w/ other forms of Psychopathology Eating disorder diagnoses are commonly associated w/ other diagnosable psychiatric conditions. In other words, there is a great deal of comorbidity. For example, patients w/ anorexia nervosa often also meet criteria for clinical depression, as well as OCD. Comorbid disorder & OCD are also found in bulimia patients. More than a third of patients w/ eating disorders also have engaged in self-harming behaviors (cutting or burning themselves) at some point in their lives. Comorbid personality (axis ii) disorders are also frequently diagnosed in people w/ eating disorders. Those w/ the restrictive type of anorexia nervosa are inclined towards personality disorder in the anxiousfearful cluster. In contrast, eating disorders that involve binge-eating/purging syndromes (both anorexia & bulimia) are more likely to be associated w/ cluster B (dramatic, emotional, erratic) problems, especially borderline personality disorders. Personality disorders are also found in patients w/ BED, although no clear pattern has emerged. Prevalence of Eating Disorders If we were to look only at the number of reports about eating disorders at the popular media, it would be easy to get the impression that these disorders are reaching epidemic proportions. However, this is not exactly true. When strict diagnostic criteria are applied, the prevalence of anorexia at any one time is around 0.28% w/ a lifetime prevalence of 0.5%. For bulimia, the point prevalence is around 1% & the lifetime prevalence is 1 to 3%. In other words, the prevalence of these disorders is actually low. Eating disorders across cultures Although majority of research on eating disorders is conducted in the US & Europe, eating disorders are not confined to these areas. Le grange, Telch, & Tibbs (1998) have reported widespread eating disorder difficulties among both Caucasians & non- Caucasians South African college students. Anorexia nervosa & bulimia have also become clinical problems in japan, hong kong, Taiwan, Singapore & Korea. Cases of eating disorders have been reported in India & Africa, & the prevalence of eating disorders in Iran is comparable to that in the US. In other words, far from being confined to industrialized western countries, eating disorders are becoming a problem worldwide. Course and outcome As we will see later, eating disorders are difficult to treat, & relapse rates are high. However, over the very long term, recovery is a possibility. Lowe & colleagues (2001) looked at the clinical outcomes of patients w/ anorexia 21 years after they had first sought treatment. Reflecting the high morbidity of

anorexia, 16% of the patients (all of them are women) were no longer alive, having died primarily from complications of starvation or from suicide. Another 10% were still suffering from anorexia, & a further 21% had partially recovered. However, 51% of the samples were fully recovered at the time of the follow up. These findings tell us that even after a series of treatment failures; it is still possible for women w/ anorexia nervosa & comorbid substance abuse appear to be at especially high risk of early death. RISK & CAUSAL FACTORS IN EATING DISORDERS Biological Factors Genetics as w/ many other disorders, the tendency to develop an eating disorder runs in families. The biological relatives of probands w/ anorexia or bulimia have elevated rates of anorexia or bulimia themselves. In one large family study of eating disorders, the risk of anorexia for the relatives of anorexia nervosa probands, was 11.4 times greater than for the relatives of the healthy controls; for the relatives of bulimia probands, the risk of bulimia was 3.7 times higher than it was for the relatives of the healthy controls. Set Point Theory set point theory invokes the well established tendency for our bodies to resist marked variation from some sort of biologically determined individual norm (the set point), at least over limited time period. Serotonin is a neurotransmitter that has been implicated in obsessions, mood disorders & impulsivity. It also modulates appetite & feeding behavior. Because many patients w/ eating disorders respond well to treatment w/ anti-depressants (w/c target serotonin), some researchers have concluded that eating disorders involve a disruption in the serotonin system. Sociocultural Factors Pressure to be thin young adolescents are avid consumers of fashion magazines. These magazines are also widely available all over the world. For example, British vogue is published in 40 or more countries & can be found in India, Argentina & Kenya among other widely diverse places. Individual Risk Factors Internalizing the thin deal Body Dissatisfaction Dieting Negative effect Perfectionism Childhood sexual abuse Family environment TREATMENT OF EATING DISORDERS Treatment of Anorexia nervosa - Tube feeding - Rigorous control of the patients eating & the monitoring of a progress towards a targeted range weight gain - Antidepressants and antipsychotic medications ( to help w/ the disturbed thinking) - Psychological interventions Treatment of Bulimia Nervosa

- Antidepressant medications.
- Cognitive- behavioral Therapy (CBT) Treatment of Binge-eating Disorder

- Well- planned CBT together w/ corrective & factual information on nutrition & weight loss is often helpful also suggest incorporation selected self-help reading materials into such a therapeutic program.

OBESITY Biological Factors Some people seem able to eat high- calorie foods without significant weight gain, whereas others become overweight easily & engage in a constant struggle to maintain their weight. Most people gain weight w/ advancing age, but this gain would be related to reduced activity & to the fact that older people are likely to continue their earlier eating habits even though they need fewer calories. Genetic inheritance contributes substantially to the tendency for some people to become obese or, alternatively, to become thin. Rates of obesity are rising far more rapidly than genetics alone could explain. This implicates unhealthful lifestyles in the development of extremes problems with weight. Psychosocial Factors In many cases the key determinants of excessive eating & obesity appear to be family behavior patterns. In some families, a high fat, high calorie diet or an over emphasis on food may produce obesity in many or all family members. In such families, a fat baby may seen as a healthy baby, & great pressure may be exerted on infants & children to eat more than they want. In other families, eating becomes a habitual means of alleviating emotional distress. Learning Perspective According to the cognitive behavioral viewpoint, a persons weight gain & his or her tendency to maintain excessive weight can be explained quite simply in terms of learning principles. For all of us, eating behavior is determined in part by conditioned responses to a wide range of environmental stimuli. Sociocultural Factors Different cultures have different concepts of human beauty. Some value slimness; others, a more rounded contour. In some cultures, obesity is valued as a sign of social influence or power. Treatment of Obesity Losing weight Diet books Dietary aids Weight loss programs

Weight loss groups - Overeaters anonymous - Weight watchers Medications - Reduces the intake of food by suppressing appetite - Preventing some of the nutrients in food from being absorbed Gastric surgery Psychological treatments

- Behavioral management method The importance of prevention Improving opportunities for physical activity Regulating food advertising aimed at children Prohibiting the sale of fast food & soft drinks in schools Subsidizing the sale of health foods