Eating Disorder

Kristian Liaury, MD, Ph.D, Psych.

Department of Psychiatry
Faculty of Medicine
Hasanuddin University
Makassar
 Why do you eat?

 Environment
 Body homeostasis
 Stomach signaling
 Brain hypothalamus
- hunger center
- satiety center
 Eating Disorders

 Eating disorders are severe

disturbances in eating behaviors,
such as eating too little or eating too
much
 Eating Disorder

 Anorexia Nervosa
 Bulimia Nervosa
 Binge Eating Disorder
 Eating Disorder Other Specified
 Eating Disorder NOS
Body Distortion Image
Anorexia Nervosa

Characteristics

•Fear of gaining weight

•Refusal to maintain
normal weight
 Anorexia Nervosa

Description
 Characterized by excessive weight loss, up to
less than 85% of body weight / BMI < 18
 Self-starvation
 Preoccupation with foods, progressing
restrictions against whole categories of food
 Anxiety about gaining weight or being “fat”
 Denial of hunger
 Consistent excuses to avoid mealtimes
 Excessive, rigid exercise regimen to “burn off”
calories
 Withdrawal from usual friends
 Anorexia

Symptoms
 Resistance to maintaining body weight at
or above a minimally normal weight for
age and height
 Begins with individuals restricting certain
foods, not unlike someone who is dieting
- Restrict high-fat foods first
- Food intake becomes severely limited
More on anorexia nervosa

 May exhibit unusual

behaviors with regards to
food.
 preoccupied with thoughts of
food, and may show
obsessive-compulsive
tendencies related to food
 may adopt ritualistic behaviors at
mealtime.
 may collect recipes or prepare
elaborate meals for others.
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Prognosis of Anorexia
 50-70% eventually recover
 May often take 6 or 7 years
 Relapse common
 Difficult to modify distorted view of self,
especially in cultures that highly value thinness.
 Anorexia is life threatening
 Death rates 10x higher than general
population
 Death rates 2x higher than other
psychological disorders
Bulimia Nervosa

Characteristics
Frequent episodes of
binge eating

Lack of control over

eating

Recurrent inappropriate
behavior
 Bulimia Nervosa

 Qualitatively distinct from

anorexia
 characterized by binge eating
 A binge may or may not be
planned
 marked by a feeling of being out of
control
 The binge generally lasts until
the individual is uncomfortably
or painfully full
 Bulimia Nervosa

 Common triggers for a binge

 dysphoric mood
 interpersonal stressors
 Intense hunger after a period of intense
dieting or fasting
 feelings related to weight, body shape,
and food are common triggers to binge
eating
 Bulimia Nervosa

 Feelings of being ashamed after a

binge are common
 behavior is kept a secret

 Tend to adhere to a pattern of

restricted caloric intake
 usually prefer low-calorie foods during
times between binges
More on bulimia nervosa

 Later age at the onset of the

disorder
 Are able to maintain a normal
weight
 Will not seek treatment until they
are ready
 Most deal with the burden of hiding
their problem for many years,
sometimes well into their 30’s
 Bulimia Nervosa

Purging Nonpurging
type type
•Vomiting •Fasting
•Laxatives •Exercise
•Diuretics
19

Prognosis of Bulimia

 ~75% recover
 10-20% remain fully symptomatic
 Early intervention linked with
improved outcomes
 Poorer prognosis when depression
and substance abuse are comorbid or
more severe symptomatology
 Age of Onset and
Gender Differences

Anorexia
nervosa is most
likely to develop 90% of
in 14- to anorexics are
18-year-olds females

Bulimia nervosa
is most likely to
develop in
women ages 15-
21
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Binge-Eating Disorder
 Recurrent episodes of binge eating; on average, at
least once a week for three months
 Binge eating episodes include at least three of the
following:
 eating more rapidly than normal
 eating until uncomfortably full
 eating large amounts when not hungry
 eating alone due to embarrassment about large
food quantity
 feeling disgusted, guilty, or depressed after the
binge
 No compensatory behavior is present
2
2
Binge-Eating Disorder
 Associated with obesity and history of dieting
 Body mass index (BMI) > 30
 Not all obese people meet criteria for binge
eating disorder
 Must report binge eating episodes and a feeling of loss of
control over eating to qualify
 Approximately 2-25% of obese may qualify
 Risk factors include:
 Childhood obesity, early childhood weight loss attempts,
having been taunted about their weight, low self-concept,
depression, and childhood physical or sexual abuse
 Physical Changes in
23

Binge-Eating Disorder
 Problems associated with obesity:
 Increased risk of Type II diabetes
 Cardiovascular disease
 Breathing problems
 Physical ailments (joint/muscle pain)
 Problems independent of obesity:
 Sleep problems
 Anxiety/Depression
 Irritable Bowl Syndrome
 Early menstruation in women
 Prognosis of
24

Binge-Eating Disorder
 About 60% (between 25 and 82%)
recover
 Binge Eating Disorder is the most
common and lasts the longest of the
three Eating Disorders
 Lasts on average: 14.4 years
Association of Eating Disorders with
Other Forms of Psychopathology

Clinical depression

Obsessive-compulsive
disorder
Eating disorders
associated with
following disorders:
Substance abuse
disorders

Various personality
disorders
26

Etiology of Eating Disorders

Genetics
 Family and twin studies support genetic link
 Body dissatisfaction, desire for thinness, binge
eating, and weight preoccupation all heritable
 Environmental factors (e.g., family interactions)
play an even greater role in etiology
27

Neurobiological Factors

 Hypothalamus not directly involved

 Low levels of endogenous opioids
 Substances that reduce pain, enhance mood, and
suppress appetite
 Released during starvation
 May reinforce restricted eating of anorexia
 Excessive exercise increases opioids
 Low levels of opioids (beta-endorphins) in bulimia
promote craving
 Reinforce binging
2
8 Neurobiological Factors

 Serotonin related to feelings of satiety

(feeling full)
 Low levels of serotonin metabolites in anorexics
and bulimics
 Antidepressants that increase serotonin often
effective in treatment of eating disorders
 Dopamine related to feelings of pleasure and
motivation
 Anorexics feel more positive and rewarded
when viewing pictures of underweight women
2
9
Cognitive Behavioral Theory
 Anorexia
 Focus on body dissatisfaction and fear of fatness
 Certain behaviors (e.g., restrictive eating, excessive
exercise) negatively reinforcing
 Reduce anxiety about weight gain
 Feelings of self control brought about by weight loss
are positively reinforcing
 Perfectionism and personal inadequacy lead to
excessive concern about weight
 Criticism from family and peers regarding weight can
also play a role
3
0
Cognitive Behavioral Theory
 Bulimia
 Self-worth strongly influenced by weight
 Low self-esteem
 Rigid restrictive eating triggers lapses, which can become
binges
 Many “off-limit” foods
 After binging, disgust with oneself and fear of gaining
weight lead to compensatory behavior
 e.g., vomiting, laxative use
 Purging temporarily reduces anxiety about weight gain
 Negative feelings about purging lead to lowered self-esteem,
which triggers further bingeing
 Stress, negative affect trigger binges
 Restrained eating plays central role in bulimia
 Restraint Scale measures dieting and overeating
3
1 Sociocultural Factors

 Society values thinness in women, muscularity

in men
 Dieting, especially among women, has become
more prevalent
 Body dissatisfaction and preoccupation with
thinness also predict eating disorders
 Societal objectification of women
 Women viewed as sexual objects
 Unrealistic media portrayals
 Women may feel shame when they don’t match the
ideal
 Overweight individuals are viewed with disdain,
creating more pressure to be thin
3
2
Gender Factors
 Objectification of women’s bodies
 Women defined by their bodies; men defined by
their accomplishments
 Societal objectification of women leads to “self-
objectification”
 Women see their own bodies through the eyes of
others
 Leads to more shame when fall short of cultural ideals
 Aging and changes in life roles (having a life
partner, or having children) associated with
decreased eating-disorder symptoms
3.
3
Treatment of Eating
Disorders
 Antidepressants
 Effective for bulimia but not anorexia
 Dropout and relapse rates high
 Limited research suggests that antidepressant
medications are not effective in reducing binges or
increasing weight loss in binge-eating disorder
3
4
Treatment of Eating
Disorders
Anorexia
 Immediate goal is to increase weight to avoid medical
complications and avoid death
 Second goal is long-term maintenance of weight gain

 CBT
 Reductions in symptoms through 1 year
 Family-based therapy (FBT) found to be effective
 Anorexia viewed as an interpersonal, rather than
individual issue
 Use of “Family Lunch” sessions
 Early results show improved outcomes over individual
therapy
3
5
Treatment of Eating
Disorders
 Bulimia
 Challenge societal ideals of thinness
 Challenge beliefs about weight and dieting
 Challenge all-or-nothing beliefs about food
 One bite of high-calorie food does not have to lead to
bingeing
 Increase self-assertiveness skills to improve
interpersonal relatedness
 Increase regular eating patterns (three meals a day)
 CBT more effective than medication
 Adding Exposure and Ritual Prevention (ERP) increases
effectiveness of CBT in the short term
3
6
Treatment of Eating
Disorders
 Binge-Eating Disorder
 CBT shown to be effective treatment
modality
 Teaches restrained eating through self-
monitoring, self-control, and problem solving
skills
 Interpersonal Therapy (IPT) equally as
effective as CBT
 Behavioral weight-loss programs may
promote weight loss.