13
Eating Disorders and Related Conditions
Chapter Outline:
I.
II.
How Eating Patterns Develop
A.
Normal Development
1.
Problematic eating habits and limited food preferences are common in
early childhood; almost a third of young children are described as picky
eaters
2.
Societal norms and expectations affect girls more than boys, particularly
by late childhood and early adolescence
B.
Developmental Risk Factors
1.
Drive for thinness is a key motivational factor for dieting and body image;
refers to the belief that losing more weight is the answer to overcoming
problems
2.
Disturbed eating attitudes are found in those as young as 7 to 10 years of
age; suggests Western sociocultural values and preoccupation with weight
and dieting may be internalized and expressed at a very young age
3.
In addition to early problematic eating behaviors, other risk factors for the
development of later eating problems include early pubertal maturation,
higher percentages of body fat, concurrent psychological problems, and
especially, weight concerns and poor body image
4.
Transition into adolescence brings many changes (including physical
maturation) which require major adjustments in self-image; weight
concerns intensify, especially for girls, who experience a “fat spurt”
associated with puberty
5.
Dieting is relatively common even among elementary school children;
chronic dieting is associated with the onset of adolescent eating disorders
6.
Dieting may lead to “false hope syndrome”- the hope of changing
appearance declines with feelings of failure and loss of control; may lead
to binge eating and purging
C.
Biological Regulators
1.
Metabolic rate, or balance of energy expenditure, is established on the
basis of individual genetic and physiological makeup, as well as eating
and exercise habits
2.
An individual’s natural weight is regulated around his or her own body
weight set point, a biologically and genetically determined range of body
weight that the body tries to “defend” and maintain
3.
Major hormonal determinants of physical growth rate during childhood
are the growth hormone and thyroid hormone, with additional gonadal
steroids kicking in during adolescence to produce a further growth spurt
and skeletal maturation
Feeding and Eating Disorders
A.
Feeding Disorder of Infancy or Early Childhood
1.
2.
3.
4.
4.
5.
B.
C.
D.
Pica
1.
Sudden or marked deceleration of weight gain and a slowing or disruption
of emotional and social development prior to age 6; can lead to physical
and mental retardation, and death
Relatively common, affecting up to a third of young children (both boys
and girls), especially those from disadvantaged environments
Onset during first two years of life can lead to malnutrition and serious
developmental consequences; can lead to, or be the result of failure to
thrive
When there is no medical reason, it is often associated with poor caregiving, including maltreatment and neglect
Risk factors include family disadvantage, poverty, unemployment, social
isolation, parental mental illness, and maternal eating disorders
Treatment involves a detailed assessment of feeding behavior and other
forms of parent-child interaction
The ingestion of inedible substances, such as hair, insects, and chips of
paint, for a period of at least one month
2.
Prevalent among institutionalized children and adults, especially those
with severe impairments
3.
Causes include poor stimulation and poor supervision in the home
environment, and in some cases of mental retardation, genetic factors
6.
Most clinical interventions emphasize operant conditioning procedures
7.
B.
Failure to Thrive
1.
Characterized by weight below the 5th percentile for age, and/or
deceleration in the rate of weight gain from birth to present of at least two
standard deviations, using standard growth charts for comparison
2.
Associated with social and economic disadvantage, and inadequate or
abusive care-giving in early infancy
3.
Developmental outcome highly related to child’s home environment; the
disorder may be the biological outcome of child abuse and neglect
Obesity
1.
A chronic medical condition characterized by excessive body fat (usually
a body mass index above the 95th percentile)
2.
Obese children are five times more likely than healthy children to
experience an impaired quality of life
3.
The proportion of children who are overweight has increased from 5% of
children in the 1960’s to 15% in the 1990’s; 10% of toddlers are now
considered overweight
4.
Although obesity in infancy and obesity in later childhood are not strongly
related, childhood-onset obesity is more likely to persist into adolescence
and adulthood
5.
Preadolescent obesity is a risk factor for later eating disorders, especially
for girls
6.
III.
The U.S. has the highest percentage of overweight children, and rates of
obesity seem to increase upon exposure to Western culture and its fast
food industries
7.
Causes include genetic predisposition (including leptin deficiencies),
improper diet, unhealthy lifestyle, as well as family influences such as
poor communication, lack of support, and in extreme cases, maltreatment
8.
Proper nutrition and reducing children’s inactivity are often the
recommended treatments; restricting diets are usually not recommended as
they can place a child at risk for medical or learning problems; schools are
making efforts to reduce risk factors for unhealthy eating and body image
Eating Disorders of Adolescence
A.
Eating disorders are most likely to appear during two time periods: the early
passage into adolescence and the transition from adolescence to adulthood
B.
Since the 1930’s media has shaped attitudes and beliefs about women’s ideal
body image, constructing a cultural preference for slimness
C.
Anorexia Nervosa
1.
Characterized by the refusal to maintain a minimally normal body weight,
an intense fear of gaining weight, and a significant disturbance in the
person’s perception of body size
2.
Denial of being too thin or having a weight problem is a notable feature of
the disease
3.
DSM-IV-TR specifies two subtypes:
a.
the restricting type, in which the individual loses weight through
diet, fasting, or excessive exercise; highly controlled, rigid, and
obsessive individuals
b.
the binge-eating/purging type, in which the individual engages in
episodes of binge eating or purging, or both; tend to have stronger
personal and family histories of obesity and higher rates of
impulsive disorders and mood problems
4.
Associated with numerous serious medical consequences due to
malnutrition
D.
Bulimia Nervosa
1.
Primary feature is binge eating- an episode of overeating that must involve
both an objectively large amount of food and lack of control
2.
Binge eating typically follows changes in mood or interpersonal stress,
although it may also be related to intense hunger due to dieting or to
feelings about personal appearance or body shape; negative feelings may
cease for a short period of time, but usually return
3.
After binging follows compensatory behaviors; the purging type
compensates through self-induced vomiting or regular misuse of laxatives
or diuretics, while the nonpurging type compensates through fasting or
excessive exercise
4.
Subtypes include dietary and dietary-depressive types; young women with
dietary-depressive subtype show more eating pathology, social
impairment, psychiatric comorbidity, and persistence of symptoms over
five years more than women with only the dietary subtype
5.
E.
F.
As with anorexia nervosa, self-evaluation is extremely influenced by body
shape and weight (although with bulimia there is not the intense drive for
thinness that is associated with anorexia, and the disturbance in perception
of body image is not as severe)
6.
Similar to those with anorexia, those with bulimia have rigid and
absolutist ways of thinking as well as dissatisfaction with and distortion of
body size
7.
Can be associated with significant medical consequences, although they
are less severe than those resulting from anorexia
8.
Binge Eating Disorder (BED)- similar to bulimia in that it involves
periods of eating more than other people would with a feeling of loss of
control, but without the compensatory behaviors; 3.1% of girls, and 0.9%
of boys
Prevalence and Development of Anorexia and Bulimia
1.
Among female adolescents, the estimated prevalence of anorexia is 0.3%
and bulimia is 1%; both disorders are thought to occur less among males
2.
Estimated female to male ratio of 11:1 for AN and 30:1 for BN
3.
Eating Disorders- Not Otherwise Specified (EDNOS) is a category of
eating disorders that covers problems that do not quite fulfill criteria for
AN or BN; prevalence may be much higher than AN and BN
4.
Young men that are affected with eating disorders show the same clinical
features as young women, but place more emphasis on athletic appearance
or attractiveness than on thinness
5.
Among American minorities, a review of eating disturbances found that
Hispanics had equal, Blacks and Asians lower, and Native American
women higher rates compared to Caucasians
6.
Western cultural ideals of weight and appearance may lead to increased
rates of eating disorders and disturbances in other cultures
7.
Onset of anorexia is usually between the ages of 14 and 18, and is
sometimes linked to stressful life events; individuals with anorexia have a
5% mortality rate, and fewer than half show full recovery; a fluctuating
pattern of restoration of normal weight followed by relapse is common
8.
Onset of bulimia is typically late adolescence to early adulthood, although
binging and purging episodes and preoccupation with weight may begin
much earlier; binge eating often develops during or after a period of
restrictive dieting; between 50% and 75% show full recovery; may follow
a chronic course or occur intermittently
9.
Although disordered eating tends to decline during the transition to early
adulthood, body dissatisfaction remains an issue for many young adults
Causes
1.
Biological Dimension
a.
Neurobiological factors play only a minor role in precipitating
anorexia and bulimia, but they likely contribute to the maintenance
of the disorders, because of their effects on appetite, mood,
perception, and energy regulation
b.
G.
Evidence supports a genetic contribution for eating disorders
(heritability of anorexia 58-88%, binge eating 46%, and vomiting
70%); what is inherited is a biological vulnerability that interacts
with social and psychological factors
c.
Imbalances in serotonin, which regulates hunger and appetite, may
be implicated with both anorexia and bulimia
d.
Biochemical similarities have been found between people with
eating disorders and those with obsessive-compulsive disorder
2.
Social Dimension
a.
For many young, white females in middle- and upper class society,
self-worth, happiness, and success are determined to a large extent
by physical appearance
b.
Sex role identification and social conformity can contribute to
eating problems
c.
Possible family influences include family dysfunction (including
conflicts and alliances among members, parental substance abuse,
and absent, uninterested, demanding, or critical caregivers), an
overemphasis on weight and dietary control, and child sexual
abuse
3.
Psychological Dimension
a.
Anorexia has been interpreted in terms of a struggle for autonomy,
competence, control, and self-respect
b.
Anorexia has also been conceptualized as a phobic avoidance of
normal adult body weight and shape
c.
Adolescents with anorexia often show a triad of personality
features: avoidance of harm, low novelty seeking, and reward
dependence (they tend to be obsessive and rigid, show emotional
restraint, prefer the familiar, have a high need for approval, and
show poor adaptability to change)
d.
Affect disturbance is a common comorbid problem with anorexia
e.
Bulimia is associated with mood swings, poor impulse control,
obsessive-compulsive behaviors, depression, anxiety, and
substance abuse
f.
Almost 90% of individuals with eating disorders also have other
Axis I disorders, usually depression, anxiety, or OCD; in addition
to genetic factors, personality characteristics such as perfectionism,
rigidness, and neuroticism may be a common link among these
disorders
Treatments
1.
Hospitalization may be required for those with high physical and/or
psychiatric risk
2.
Antidepressants and serotonin-reuptake inhibitors (SSRIs) may be helpful
for bulimia, but not for anorexia
3.
Psychosocial interventions are proving to be effective at treating eating
disorders and are generally more effective than medications alone
4.
5.
6.
7.
Resolution of family problems, such as parental psychopathology, family
isolation, and a poor parent-child relationship may a crucial part of
treatment
Anorexia is generally less responsive to treatment than bulimia
For anorexia, family-based interventions are often required to restore
healthy communication patterns, and cognitive-behavioral methods may
be used to modify the patient’s rigid beliefs, self-esteem, and self-control
processes
For bulimia, cognitive-behavioral therapies that focus on attitudes, beliefs,
feelings, and behaviors supporting problematic eating are very effective,
as is interpersonal therapy that addresses situational and personal issues
contributing to the development and maintenance of the disorder