Eating Disorders

1
Eating Disorders

• Chapter 22
• Eric Stice and Cara Bohon

2
HISTORICAL CONTEXT

• Anorexia nervosa was first recognized as a
  psychiatric disorder more than a century ago.
• Stunkard (1959) first described binge eating
  disorder half a century ago among overweight
  individuals.
• Binge eating disorder has not yet been recognized
  as a diagnostic entity but considerable research
  has led to the likely inclusion of the disorder
  in the next edition of the DSM.
• Bulimia nervosa was recognized as a psychiatric
  disorder in the late 1970s.

3
DIAGNOSTIC ISSUES AND DSM-IV CRITERIA

• Anorexia Nervosa
• Weight loss or failure to gain weight (with
  weight less than 85 of what would be expected
  for height, age, and developmental level)
• Intense fear of gaining weight or of becoming fat
  despite a low body weight
• Disturbed perception of weight and shape
• An undue influence of weight or shape on
  self-evaluation or a denial of the seriousness of
  the illness
• Amenorrhea in postmenarcheal females
• Bulimia Nervosa
• Marked by recurrent episodes (at least twice
  weekly for 3 months) of consumption of unusually
  large amounts of food (coupled with a sense that
  the eating is out of control)
• Recurrent (at least twice weekly for 3 months)
  compensatory behaviors to prevent weight gain
  (e.g., self-induced vomiting, laxative/diuretic
  abuse, fasting, or excessive exercise)
• Undue influence of weight and shape on
  self-evaluation

4
DIAGNOSTIC ISSUES AND DSM-IV CRITERIA

• Binge Eating Disorder
• Binge eating disorder is listed in the DSM-IV
  (American Psychiatric Association, 2000) as a
  provisional eating disorder requiring further
  study, exemplifying an eating disorder not
  otherwise specified (EDNOS).
• This eating disorder involves
• Repeated episodes (at least 2 days per week for 6
  months) of uncontrollable binge eating
  characterized by certain features (e.g., rapid
  eating, eating until uncomfortably full, eating
  alone because of embarrassment, and feeling
  guilty or depressed after overeating)
• Marked distress regarding binge eating
• The absence of regular compensatory behaviors
  (e.g., monthly vomiting for weight control)

5
DIAGNOSTIC ISSUES AND DSM-IV CRITERIA

• Eating Disorder Not Otherwise Specified (ED-NOS)
• The DSM-IV currently describes five symptom
  presentations in addition to binge-eating
  disorder as examples of Eating Disorder Not
  Otherwise Specified (EDNOS)
• Anorexia nervosa with menses present
• Anorexia nervosa with normal weight
• Low-binge frequency bulimia nervosa
• Chewing and spitting food repeatedly
• Purging disorder (the regular use of
  inappropriate compensatory behavior after eating
  food that would not be considered a binge
  episode)

6
PREVALENCE

• Between 0.9 and 2.0 of girls and women and
  between 0.1 and 0.3 of boys and men experience
  anorexia nervosa during their lifetimes (Hudson,
  Hiripi, Pope, Kessler, 2007 Lewinsohn
  Striegel-Moore, Seeley, 2000).
• Bulimia nervosa afflicts between 1.1 and 4.6 of
  girls and women and between 0.1 and 0.5 of boys
  and men during their lifetimes (Garfinkel et al.,
  1995 Hudson et al., 2007).
• Binge eating disorder afflicts between 0.2 and
  3.5 of girls and between 0.9 and 2.0 of boys
  and men during their lifetimes (Hoek van
  Hoeken, 2003 Hudson et al., 2007).

7
RISK FACTORS, PROTECTIVE FACTORS, AND ETIOLOGIC
FORMULATIONS

• Anorexia Nervosa
• Picky eating and digestive problems in early
  childhood
• Premature birth and cephalhematoma
• Infant feeding problems
• Maternal depressive symptoms
• Thin-ideal internalization and body
  dissatisfaction
• Depressive symptoms and psychological
  disturbances
• High self-esteem and higher maternal body mass
  index appear to be protective factors.

8
RISK FACTORS, PROTECTIVE FACTORS, AND ETIOLOGIC
FORMULATIONS

• Bulimia Nervosa

• Binge Eating Disorder

• Body dissatisfaction
• Preoccupation with thinness by family members and
  peers
• Dietary restraint
• Negative affect
• Deficits in social support
• Substance abuse
• Elevated body mass
• Early feeding problems

• Initial elevations in body mass
• Perceived pressure for thinness
• Body dissatisfaction
• Dietary restraint
• Negative affect
• Tendency to eat in response to negative emotions
• Depressive symptoms

9
GENETIC AND OTHER BIOLOGICAL FACTORS

• Heritability
• Relatives of individuals with eating disorders
  are at elevated risk for eating pathology
  (Strober et al., 2000).
• Genetic studies
• Evidence suggesting a genetic basis for anorexia
  and bulimia nervosa has emerged from molecular
  genetics studies but almost no reliable findings
  have emerged from genetic research on eating
  disorders.

10
GENETIC AND OTHER BIOLOGICAL FACTORS

• Neuroendocrine and neurohormonal factors
• Serotonergic
• Histamergic
• Various peptidergic systems
• Brain structure and functioning studies
• Gray and white matter loss
• Increased ventricular size
• Increased cerebrospinal fluid volume
• Enlarged sulci

11
DEVELOPMENTAL PROGRESSION

• Anorexia Nervosa
• Two peak periods of risk for anorexia nervosa
  onset Around ages 14 and 18 (APA, 2000).
• Among adolescents with anorexia nervosa
• 50 to 70 will recover
• 20 will show improvement but will exhibit
  residual symptoms
• 10 to 20 will develop a chronic course (Berkman
  et al., 2006 Wilson et al., 2003).
• Course of illness is on average 10 years
  (Strober, Freeman, Morrell, 1997).
• Approximately 6 of patients diagnosed with this
  disorder die per decade of illness.
• The suicide rate for anorexia nervosa is 57 times
  higher than in the general population (Keel et
  al., 1997).

12
DEVELOPMENTAL PROGRESSION

• Bulimia Nervosa
• Peak period of risk for onset for bulimia nervosa
  is between 14 and 19 years of age for females
  (Lewinsohn et al., 2000 Stice et al., 2009).
• Community-recruited samples suggest that bulimia
  nervosa typically shows a chronic course
  characterized by periods of recovery and relapse
  (Bohon, Stice, Burton, 2009).
• Studies have suggested that both diagnosable and
  subthreshold bulimia nervosa are associated with
  future onset of
• Depression
• Suicide attempts
• Anxiety disorders
• Substance abuse
• Obesity
• Health problems
• (Fairburn, 2000 Johnson et al., 2002 Stice,
  Cameron, Killen, Hayward, Taylor, 1999 Stice,
  Hayward, Cameron, Killen, Taylor, 2000
  Striegel-Moore, Seeley, Lewinsohn, 2003).

13
COMORBIDITY

• Anorexia Nervosa
• Adolescent comorbidity
• Dysthymia, bipolar disorder, agoraphobia, simple
  phobia, marijuana dependence, and oppositional
  defiant disorder
• Anxiety disorders often predate the eating
  disorder, and depression often persists
  postrecovery (Kaye, Bulik, Thornton, et al.,
  2004 Sullivan, Bulik, Fear Pickering, 1998).
• Bulimia Nervosa
• Adolescent comorbidity
• Major depression, dysthymia, bipolar disorder,
  agoraphobia, social phobia, alcohol dependence,
  marijuana dependence, and conduct disorder, but
  not with current simple phobia, overanxious
  disorder, panic disorder, posttraumatic stress
  disorder, generalized anxiety disorder,
  obsessive-compulsive disorder, oppositional
  defiant disorder, attention deficit hyperactivity
  disorder, or other substance use disorders (Stice
  Peterson, 2007).

14
COMORBIDITY

• Binge Eating Disorder
• The National Comorbidity Survey Replication found
  that 78.9 of respondents with binge eating
  disorder met criteria for at least one DSM-IV
  disorder, although no particular disorder stood
  out as being more common than others among those
  with binge eating disorder (Hudson et al., 2007)

15
SEX DIFFERENCES and CULTURAL CONSIDERATIONS

• Female to male sex ratios of the prevalence of
  anorexia nervosa and bulimia nervosa are
  approximately 101 (APA, 2000).
• Striegel-Moore et al. (2005) noted different
  patterns of eating disorder symptoms across
  ethnic/racial groups, reporting that binge eating
  in the absence of purging was more common in
  African American women, whereas purging in the
  absence of binge eating was more common in
  Caucasian women.
• Several studies have found no racial or ethnic
  differences in the prevalence of recurrent binge
  eating, eating disorder symptoms, or risk factors
  for eating disorders (Smith et al., 1998).
• One consistent difference is that African
  Americans report less body image dissatisfaction
  than their white counterparts.(Kronenfeld,
  Reba-Harrelson, Von Holle, Reyes, Bulik, 2010).

16
SYNTHESIS AND FUTURE DIRECTIONS

• Developmental processes that give rise to eating
  disorders are currently incomplete.
• Another key gap in the literature regards
  maintaining factorseither psychosocial or
  biologicalthat perpetuate eating-disordered
  behaviors once they emerge.
• An improved understanding of risk factors is
  essential for the design of more effective
  prevention programs, and improved understanding
  of maintenance factors is vital for the
  development of more effective treatment
  interventions.