What are eating disorders? - Chapter 10

Eating disorders are complex and rooted in psychological, sociological and cultural phenomena. Developmental and psychological processes can be vulnerability factors in the development of eating disorders.

What is Anorexia Nervosa?

Anorexia nervosa (AN) is an eating disorder primarily characterized by a refusal to maintain a minimal weight, a pathological fear of gaining weight, and a distorted body image in which clients persist in the belief that they are overweight. Ten times as many women as men have this disorder. The 12-month prevalence for women is around 0.4%.

The DSM-5 criteria for anorexia nervosa are:

• A significantly reduced caloric intake than the body requires, leading to a significantly underweight;
• Intense fear of gaining weight or getting fat;
• A disturbance in the way the patient views his own body, unnecessary influence of weight or body shape on the self-evaluation.
• An objective way to measure the severity of symptoms is with the body mass index (BMI). This can be used to measure whether an individual is in a healthy weight class by including both the height and the weight of a person.

The DSM-5 distinguishes between two different types of anorexia nervosa:

1. The restrictive type: in this type, self-starvation is not accompanied by, for example, vomiting.
2. The purging type: in this type, the patient regulates his weight with the help of purging: 'cleansing', for example by vomiting or using laxatives.

Anorexia is associated with various biological symptoms, due to its severe effect on the body. These include:

• Fatigue, cardiac arrhythmias, hypotension, low blood pressure and slow heart rate
• Dry skin and brittle hair
• Kidney problems and gastrointestinal problems
• Development of lanugo over the body
• Absence of menstrual cycles (amenorrhea)
• Hypothermia.

Anorexia has high comorbidity with other psychiatric disorders, such as depression, OCD, and social anxiety disorder.

What is Bulimia Nervosa?

Bulimia nervosa (BN) is an eating disorder characterized by a fear of gaining weight and impaired body perception in which there are recurrent episodes of binge eating followed by periods of purging or fasting. The difference with the purging type of anorexia is that bulimia patients are not overweight or underweight. About 90% of bulimics are female. Life prevalence in women is between 1% and 3%.

The DSM-5 criteria for bulimia nervosa are:

• Repeated binge eating;
• Frequent inappropriate compensatory ways to avoid gaining weight, such as vomiting, fasting or exercising excessively;
• Binge eating and compensatory behaviors occur on average at least once a week for three months;
• Self-image is too much influenced by body shape and weight.
• The purging provides a liberating feeling after the unpleasant feeling that an individual gets from the uncontrolled eating.
• Bulimia has high comorbidity with other psychiatric disorders, including depression, SAD, and personality disorders.

What is Binge Eating Disorder (BED)?

Binge eating disorder (BED) is an eating disorder in which there are recurrent episodes of binge eating that are not followed by periods of purging or fasting as in bulimia. Therefore, patients are often overweight and often face failure in weight loss efforts. The difference with bulimia is often difficult and depends on how often the patient exhibits compensatory behavior. BED is also seen as a severe form of bulimia. The lifetime prevalence of BED is around 3%, about one and a half times as many women as men have the disorder.

The DSM-5 criteria for BED are:

• Repeated binge eating
• Binge eating is associated with at least three of the following:  eating faster than usual, eating until you are uncomfortably full, eating a lot when you are not hungry, eating alone because you feel embarrassed because of the amount and feel gross, depressed, or guilty after binge eating
• Suffering from binge eating
• The binge eating is not associated with inappropriate compensatory behaviors as seen in bulimia
• BED is associated with depression, impaired work-related and social functioning, low self-esteem, and bodily dissatisfaction

What are cultural differences regarding Eating Disorders?

Many studies suggest that cultural differences and changes are associated with differences in vulnerability to developing eating disorders and thus may represent risk factors. The emphasis placed on weight and body shape in Western cultures is an important contributor to the development of eating disorders. Thus, bulimia seems to arise only in individuals exposed to Western ideals.

White Latinas have thinner body ideals than black women. African American women are also more satisfied with their body shape, so these women are more likely to have bulimia than anorexia. Anorexia also occurs in parts of the world that are not or little exposed to Western influences. Thus, the refusal of food does not seem to be necessarily due to the presence of weight concerns and body dissatisfaction.

Which demographic factors play a role?

The fact that women are ten times more likely to have an eating disorder seems to be due to the idealization of women's weight, size and body shape in the Western media. This makes being thin an important social value. In addition, women are more often defined by their bodies and men by what they have achieved. Eating disorders are more common in gay men than in heterosexual men.

What is the aetiology of Eating Disorders?

Due to the complexity of eating disorders, it is known which factors are involved, but not exactly how they influence the development of eating disorders. There are several risk factors that will be discussed. Anorexia and bulimia often share the same risk factors, but it is not known why an individual develops one disorder and not the other.

What are genetic factors?

Eating disorders have a genetic component, first degree relatives of individuals with anorexia and bulimia are more likely to have these disorders than relatives of people not diagnosed with these disorders. Twin studies show that the genetic component is about 40% to 60%.

Studies suggest that the genes that contribute to developing anorexia are different from those for bulimia. This is because bulimia appears to be culture-bound, but anorexia is not. It is therefore likely that there is a genetic component to self-starvation in anorexia, but more research is needed.

What are neurobiological factors?

Animal studies show that lesions in the lateral hypothalamus can cause loss of appetite, which can result in a self-starvation syndrome that is behaviourally similar to anorexia. However, individuals with anorexia often feel hungry and hormonal imbalances appear to be a result of the disorder rather than a cause of the disorder.

Self-starvation and maintenance of low body weight can be enhanced by endogenous opioids that the body releases to reduce pain sensations. In addition, low levels of serotonin metabolites (products left after breaking down serotonin) are found in individuals with anorexia and bulimia. Serotonin makes you feel full, so people with low levels of serotonin metabolites are prone to binge eating. Finally, patients with anorexia and bulimia show a greater expression of the dopamine transporter gene DAT. Dopamine transporter genes control the entry and exit of drugs into cells. Due to the greater expression of the DAT gene, patients may be more susceptible to the rewarding effects of eating.

What are the sociocultural influences?

Media influence is a term that describes changes in a person's attitudes, behavior and morals that are directly influenced by the media. For example, body dissatisfaction appears to be related to watching certain TV shows. Another important factor is 'food and eating fashion'. The more low-calorie diets become the trend, the greater the risk of developing eating disorders. In addition, obese people are attributed all kinds of negative characteristics, which only increases the fear of becoming fat.

Body dissatisfaction (BD) is the gap between one's real and ideal weight and body shape. This dissatisfaction easily triggers bouts of dieting: a restricted eating regimen followed for weight loss or medical reasons. BD and diets are important vulnerability factors in developing eating disorders, but not enough. There are enough people who think that their body deviates from the ideal body but are happy with this. Also, many people who suffer from BD do not develop an eating disorder.

What is peer influence?

Peer influences is a term that describes changes in a person's attitudes, behavior and morals that are directly influenced by peers. Eating and dieting habits can be significantly influenced by close contact with peers. However, it is difficult to determine whether these influences determine attitudes towards food and body shape and have a significant influence on the development of eating disorders.

What is family influence?

Minuchin's family systems theory states that a patient is entrapped in a dysfunctional family structure that increases the development of an eating disorder. These families have one or more of the following characteristics:

• Enmeshment: Parents are pushy, overinvolved in their children's affairs, and dismissive of their child's emotions and emotional needs
• Overprotection: here family members are too busy with the upbringing and the well-being of others, the child can experience this as excessive control by the parents
• Rigidity: there is a tendency to maintain the status quo in the family
• Lack of conflict resolution: families avoid conflict or are in constant conflict
• Mothers of children with eating disorders are themselves more likely to have dysfunctional eating patterns and psychiatric disorders. In addition, these mothers are often critical of their daughters' appearance, weight and attractiveness, compared to mothers who do not have children with eating disorders.

The factors described together are called familial factors. However, it is not the case that these factors are causal in nature, it is likely that other (for example, biological or psychological) factors are required to ultimately trigger the development of an eating disorder.

What are the experiential factors?

Negative experiences can be vulnerability factors for developing eating disorders. A specific risk factor is childhood sexual abuse. Sexual abuse increases the risk of anorexia and bulimia. However, it is difficult to determine how this influences the development of eating disorders, as sexual abuse is also a risk factor for a variety of other psychiatric disorders. It is possible that negative experiences can trigger other forms of psychopathology that mediate the development of eating disorders. An eating disorder can also be a way to deal with emotional and identity problems. Finally, an eating disorder can allow a person to develop a coherent self-image by focusing attention on a specific aspect of life.

What are the psychological and dispositional factors?

Several studies have identified personality traits characteristic of individuals with eating disorders. These include:

• Perfectionism
• Shyness
• Neuroticism
• Low self-esteem
• High introspective awareness
• Negative or depressed affect
• Dependence and being unassertive.

Negative affect refers to the full spectrum of negative emotions. That this is a characteristic of anorexia and bulimia patients is in line with the fact that mood disorders are often comorbid with anorexia and bulimia. There is disagreement about whether negative affect is a cause or effect of eating disorders. There is both evidence that it is a consequence of the disorder and that it plays an active role in generating symptoms such as body dissatisfaction.

Low self-esteem means that a person values ​​himself negatively. Low self-esteem predicts eating disorders in women and is therefore not just a consequence of it. In addition, eating disorders such as anorexia are sometimes seen by researchers as a way to combat low self-esteem by having control over a specific area of ​​life: eating.

Perfectionism is setting incredibly high standards of performance, with excessive self-criticism. Perfectionism can be self-oriented, where a person sets high standards for themselves, and it can be others-oriented, where a person tries to live up to the high standards set by others. Perfectionism can be adaptive, where a person tries to achieve the best possible outcome, and it can be maladaptive, where a person tries to achieve impossible goals. Perfectionism is strongly associated with body dissatisfaction and the pursuit of being thin. In addition, it is also a characteristic of many other psychological disorders.

What are the cognitive deficits?

Eating disorders can be conceived as involving either too much or too little control over eating behaviour. This leads to the possibility that cognitive control of eating behaviour may be impaired in some conditions. In the case of BED, many associations have been found between uncontrolled binge eating, and deficits in the cognitive processes that are required to control and regulate behaviour. For example, individuals with BED perform worse on tests of executive functioning, show ineffective inhibitory control of the prefrontal cortex, and demonstrate a negative relation between working memory and body weight. Other cognitive deficits are:

• Deficits in emotional regulation
• Poor top-down regulation and inhibition of food cravings
• Impairments of working memory caused by increased levels of anxiety and depression in obese individuals that worsen executive function performance when control of eating is required.

What are Transdiagnostic Models of Eating Disorders?

The transdiagnostic cognitive-behavioural model is a model of eating disorders that posits that a dysfunctional system of self-evaluation is central to the maintenance of eating disorders and that self-worth is defined in terms of control overeating, weight, and shape, which in turn leads to a restricted diet. Other subordinate mechanisms that maintain eating disorders in this model include low self-esteem, clinical perfectionism, interpersonal problems, and mood intolerance.

How can Eating Disorders be treated?

Eating disorders are difficult to treat. There are several challenges involved:

• Patients often deny that they are ill or have a disorder. 90% of people with diagnosable problems therefore do not receive treatment.
• Patients with severe eating disorders often require both medical and psychological treatment. In the case of anorexia, hospitalization and prevention of death by self-starvation are often necessary, among other things.
• Eating disorders are often highly comorbid with other psychological disorders, making treatment complex.

There are pharmacological treatments, family therapy, and CBT. Self-help groups and alternative delivery systems are also used. Alternative delivery systems give patients access to services that may not receive other forms of treatment. This includes, for example, treatment and support via telephone therapy, email, the internet, computer software, CDs and virtual reality techniques.

What pharmacological treatments are there?

Pharmacological treatments are drug-based treatments for psychopathology. Because anorexia and bulimia patients are often also depressed, antidepressants are often prescribed. The best results in bulimia have been achieved when antidepressants were used in combination with CBT. Pharmacological treatments for anorexia are much less successful than for bulimia. Pharmacological treatments have a higher drop-out rate than psychological therapies and all sorts of side effects.

What is family therapy?

One of the most commonly used therapies for eating disorders is family therapy. This comes from the previously discussed family systems theory, which states that a patient is entrapped in a dysfunctional family structure that increases the development of an eating disorder. With therapy, the dysfunctional characteristics can be discussed and treated.

The Maudsley approach is a multi-stage family therapy for eating disorders. The first phase focuses on how the family can help solve the problems they encounter, the second phase helps the family to challenge the symptoms of the eating disorder, and the third phase develops family relationships and activities as recovery takes place found it.

What is Cognitive Behavioural Therapy (CBT)?

For bulimia, the most recommended therapy is CBT. CBT for bulimia is based on the transdiagnostic cognitive model discussed earlier. There are three stages of CBT needed to deal with bulimia symptoms and underlying dysfunctional cognitions:

• Meal planning and stimulus control
• Cognitive restructuring to discuss dysfunctional beliefs about weight and shape
• Developing methods to prevent relapse

There is also an 'enhanced' form of CBT that can be used for all eating disorders. This focuses on the motivation to change and helping to gain weight and discussing psychological problems related to weight and shape.

CBT has been successful in treating bulimia for several symptoms. The advantages here are that improvement can be seen immediately and that the therapeutic effect of the treatment remains for at least five years after treatment.

What are Prevention Programs?

Prevention programs are treatment programs that try to prevent the onset of psychopathology before the first symptoms are visible. Programs taught in schools seek to:

• Teach vulnerable populations about eating disorders, their symptoms and causes;
• Help individuals to reject media and peer pressure to be thin; and
• Identify risk factors for eating disorders, such as dieting, body dissatisfaction, and so on.