Chapter 10.

Eating Disorders

1. Eating Disorders

Major DSM-5 eating disorders

- Anorexia nervosa and bulimia nervosa

- Pica. Eating of non-food substances for at least 1 month period and at a daily basis (paper,
soap, cloth, string…)

• Usually, a childhood disorder

• Minimum age of 2 years

- Rumination Disorder. Someone repeatedly chews on their food, repeatedly regurgitates it.
At least for 1-month period. More likely to happen in children. Rare. No due to disgust,
they may even find the process enjoyable. It may be that the regurgitated food is
• Re-chewed
• Re-swallowed
• Spit out

- Avoidant/Restrictive Food Intake Disorder. Avoid eating certain foods because of a lack of
interest in it.
• Maybe because of secondary sensory characteristics.
• May be some concern about aversive consequences (trouble swallow, for
example)
• As a result, they often lose weight or have significant nutritional deficiency
• Interferes with their functioning

- Binge Eating Disorder. Compulsive over-eating. People consume huge amounts of food
while feeling powerless to stop.
• Binges often last around 2 hours. Can go on and off all day long
• Continue to eat even when not hungry and long after they are full
• Sometimes they eat so quickly they might not even register exactly what it is they
are eating

1. Binge-Eating Disorder

- Recurrent binge eating characterized by both of the following (1 per week for 3 months):
• Eating a much larger amount of food than most people in a discrete period
• Not being able to control overeating

- Associated with 3 or more of the following:

• Eating more rapidly than normal
• Eating until uncomfortably full
• Eating large amounts when not hungry
• Eating alone because embarrassed about amount eating
• Feeling disgusted/guilty with self

- Marked distress about the binge eating

Different from obesity

- More impaired than obese people
- Lower quality of life
 - Feel more subjective distress
- More psychiatric co-morbidity

Two most common types of eating disorders

- Anorexia nervosa and bulimia nervosa
- Severe disruptions in eating behavior
- Extreme fear and apprehension about gaining weight

2. Bulimia Nervosa

2.1. Characteristics

- Binge eating episodes on a recurrent basis

- Compensatory behaviors to prevent weight gain

• Purging. Self-induced vomiting, diuretics, laxatives
• Non-purging. Exercise excessively or fast

- Occurs at least once per week for 3 months

- Self-evaluation is unduly influenced by body shape and weight. Often their perceptions are
distorted and inaccurate.

- Within +/- 10% of expected weight.

• Not usually underweight or overweight

• When we start moving into severe underweight, like 85% of expected body
weight, we are moving towards anorexia

Video. Bulimia Nervosa.

- Bulimia highly associated with suicidal ideation, higher rates than the general population,
but not as high as anorexia is.

- Cognitive error. They only purge 10 to at most 50% of the calories that they’ve consumed,
and it depends on how quickly they purge.

- May be a feeling of relief that drives this behavior combined with maintaining the regular
weight.

2.2. Statistics

- Majority female

- Age of onset is approximately 16 -18 years

- Lifetime prevalence 1.1% females, 0.1% males

- 6-8% of college women suffer from bulimia

- Suicide rates higher than general population but lower than anorexia
 - Long-term studies reveal 68 to 75 percent recover, although about 10 to 20 percent
remain fully symptomatic
2.3. Associated Medical features

- Erosion of dental enamel, electrolyte imbalance

- Kidney failure, cardiac arrhythmia, seizures, intestinal problems, permanent colon damage

2.4. Associated Psychological Features

- Most are very concerned with body shape

- Fear gaining weight

- High comorbidity – anxiety, mood, and substance abuse

2.5. Socio-cultural aspect of bulimia

2.5.1. Race and Bulimia

African American adolescents tend to have less body dissatisfaction, fewer weight concerns, a
positive self-image, and perceive themselves as thinner than they actually are compared to
Caucasian girls
- Lower rates of anorexia and bulimia in AA individuals, being anorexia almost nonexistent

 Potential role for culture in contributing to the onset of these eating disorders

2.5.2. Culture

- 50 Egyptian women in London universities vs. 50 Egyptian women in Cairo universities (not
randomized)
- 12% in London had eating disorder, 0% in Cairo

- Replicated with Asian women coming to US. Similar results. Rates much higher here.
 - Eating disorders tend to be a Western phenomenon. We don’t see them cross-culturally as
we do with other disorders like mood or anxiety disorders.

What is it about Western culture that might encourage the development of these eating disorders?
What does the culture hold up as a standard for beauty?

- Miss America. Extremely thin body type.

• Trend in Body Mass Index (BMI) over 80-year spam of Miss America Pageant
Winners (1922 – 1999). Ratio of your height to weight
- A healthy BMI is somewhere between 18 and 25
- Anything below 18 is considered in the malnourished range

• Overtime, BMI is trending down

- Starting in the 1970s. Common for the BMI to be below the range that
indicates malnutrition or excessive low weight

 Message. Extreme thinness is considered to be beautiful

While the trend is going down for Miss America, the trend is going up for women in the American
society. The average woman BMI is increasing overtime.

- Conflictive message
This messages not only come from Miss America, but also from
- Magazines.
• Diet and exercise advertising very common in these magazines, particularly
starting in the mid 80s.

• Study.
- Adolescents who were at risk of an eating disorder because they were
dieting

- Randomly assigned them to receive either a fashion magazine

subscription or a non-fashion magazine subscription

- They followed the girls for 15 months

- Girls that had received fashion magazines showed significant increase in

their body dissatisfaction compared to the other condition.

- TV Shows / Movies.
• Mismatch between what the expectations for beauty are in women vs. men

• Studies suggest that girls who watch 8 or more hours of TV a week report
significantly more body dissatisfaction.

- News Media
• Not uncommon for there to be a younger attractive woman paired with an older,
less attractive male.

- Cartoons
• Men can be chubby and overweight and women much more slender

• Overweight men are 5 times more likely to be on TV than overweight women

2.5.3. Social Media

Fairly strong link between media exposure and eating disorder symptoms. The more media that an
adolescent is exposed to, the more likely they are to develop these eating disorder symptoms.

- Greater media exposure leads to greater body dissatisfaction, which in turn leads to
greater eating disorder symptoms.
Another study. Replicated several times
- Present different images of body types

- Would ask women participant to rate what their body type was lined up with the examples

• On average, woman would say around 3.5

• When asked about what they thought the ideal body type was they would go
down the scale towards more skinny images.

• When men were asked about woman, the ideal body type was somewhere in
between women current’s and ideal

- Men asked about themselves. Current and ideal pretty similar

• Men don’t seem to have the same pressure to feel skinny.

• Women rate the ideal as a bit more skinny

 Western culture emphasizes thinness as a value.

 Major role in the development of eating disorders pathology in our adolescents’ girls.

2.6. Cognitive Features. Factors that could be maintaining bulimia

- Associated Cognitive Features

• Overly concerned with body shape

• Fear gaining weight

• Hypervigilant for any signs of weight gain

• Selective attention for aspects of physical appearance that are viewed negatively
Study. Looked at cognitive biases among people that had symptoms of bulimia and those who
didn’t.

- Took pictures of the participants

- Participants looked at them later on and at pictures of other people as well

- They also had to identify parts of themselves that they found to be attractive and parts of
themselves that they believed were unattractive

- Tracked their eye gaze. How much time did each of the groups spend looking at their own
body parts that they considered attractive and unattractive vs. other people’s body parts
that the other people considered attractive or unattractive

• Healthy controls.
- Own pictures. Spent equal amount of time looking at their body parts that
they considered ugly vs most beautiful

- When looking at images of other bodies. Spent less time looking at what
other people considered their most beautiful parts and more time looking
at other people’s less attractive body parts.
• Protective bias
• People with bulimia
- Own pictures. Spent more time looking at their most ugly body parts and
far less time on the more attractive body parts

- Other’s pictures. Spent more time looking at their most beautiful body
parts and less time on the more unattractive body parts

• Negative bias regarding their selective attention

Consistent with other research where bulimic women judge their body size to be larger and their
ideal of weigh lower than what people without bulimia indicate. More impact on body image of
eating a candy.
- If we did the same after people had eating, these patterns may have been enhanced even
further

Video. Bulimia Nervosa

 2.7. Treatment

2.7.1. CBT

There is not a strong evidence base for bulimia. Not enough treatment trials. However, enough
studies to think that CBT treatment seem to be a reasonably effective treatment

- Begins with patient education about bulimia

• Physical consequences of binge eating

• Ineffectiveness of vomiting and laxative use for weight control

• Only lose 10-50% of calories if you purge right away

- Meal scheduling. Behavioral intervention

• 5 or 6 small meals a day, with no more than 3 hours between meals.
- If we can stop somebody from getting hungry, we might be able to
prevent some of these binges

- More frequent but smaller meals  Less likely to have a binge

- Cognitive therapy. Identify more accurate ways

• Altering dysfunctional thoughts and attitudes about body shape, weight, eating

- Coping strategies developed

• Identify events, thoughts, and feelings that trigger an urge to binge and then to
learn more adaptive ways to cope

• Do not spend time alone after eating in early stages of treatment

• Coping strategies to deal with setbacks

- Short-term treatment - 5 months, not years

Large RCT examined CBT vs psychodynamic treatment (long-term treatment)

- Psychodynamic treatment assumes:
• Need to ward off inner feelings but difficulty doing so
• Reflect on and tolerate negative affect
• Examine how eating contributes to affect

- Weekly 50-minute sessions for two years

- On average, 72 sessions! CBT 20 to 25 sessions, so almost 3 times as many sessions in the

psychodynamic

- 70 patients randomized to each condition

- Results. Main outcome. Had they had any binge or purge episodes in the previous 30 days?
• At the beginning of the study everybody had

• Forward 5 months. When treatment ended for the CBT treatment

 - CBT. About 40% no longer endorsing in bingeing or purging in the past 30
days
- PSYCH. Roughly 10%

• 25 months after starting treatment

- CBT. About the same level
- PSYCH. Slight increase, CBT still superior even there is no longer any
treatment

 CBT provides skills they can still use even after the treatment has ended

 Vast majority in both conditions still have episodes of binge eating and purging. Vast
majority still don’t show a clinically significant response

 31% still met diagnostic criteria for bulimia

The American Journal of Psychiatry

2.7.2. Medication

- FDA approved Prozac for eating disorders

- Antidepressants seem to work for bulimia in short term compared to placebo

• Less evidence about long term efficacy

- Evidence that Prozac can be helpful for people with bulimia who did not respond to
therapy

- However, other evidence that CBT plus placebo was more effective than CBT plus Prozac
(acute and 12 months)
 • Something interferes with the effectiveness of CBT

Try CBT first. Family based treatments could be also effective, but poor research.

3. Anorexia Nervosa

3.1. Characteristics

- Restriction of energy intake leads to low body weight (85% or less of what is expected)
• Intense fear of gaining weight that prevents them from eating

• Disturbance in way in which one’s body weight is experienced, undue influence on

self-evaluation, low recognition about low weight

• Major distinction from bulimia is low weight

• Occasionally they’ll also be binges followed by fairly severe restriction

- Age of onset typically adolescence

- Dieting during adolescence years is often a precipitating factor in the onset of eating
disorders

- Perfectionism

- Being hungry all the time

Video. Anorexia Nervosa

Consequences
- Thin hair, brittle nails, yellowish skin tinge

- Lanugo (downy hair on face, arms, back, legs; baby hair)

- Low blood pressure

- Problems with temperature regulation

- Vitamin B1 deficiency (depression link)

Prevalence
- Anorexia:
• Point prevalence: 0.28%
• Lifetime prevalence: 0.50%

Does not remit very quickly without treatment, and even with treatment it can take some time to
recover from anorexia. Prevalence low, but it’s a persistent disorder when it does happen.

- Comorbidities with
• Substance abuse
• Obsessive compulsive disorder
• Major depressive disorder, usually secondary to anorexia

3.2. Long-term Outcome in Anorexia

Prolonged course.
- Followed 95 patients (aged 12-17) for 10 – 15 years

- 30% of patients had relapses following hospital discharge

- 76% met criteria for full recovery

- Time to recovery ranged from 57–79 months depending on definition of recovery

3.3. Etiology

- Complex interaction of biological, sociocultural, and individual variables

• Genetics: Clearly plays a role
• Risk for relatives of anorexic patients 11.4x greater than for relatives of
healthy controls (Strober et al., 2000)

3.4. Risk Factors

3.4.1. Obstetrical Complications

- Compared 781 girls with anorexia between 10 to 21 years old to 3905 controls on rates of
pre-term birth and birth trauma

- Swedish study with extensive hospital records

- Few risk factors for developing anorexia emerged

• Young maternal age (15-19)

• Not making it to full term pregnancy. Gestational age of less than 32 weeks

• Cephalhematoma. Bruising around the head, suggesting the possibility of brain

damage occurred during the delivery
 3.4.2. Perfectionism as a Risk Factor?

Largest study to date that documented higher perfectionism scores among patients with anorexia
(n= 322).
- We don’t know if it was present before the development of anorexia

3.4.3. Family Environment

- Childhood sexual abuse?

• Meta-analysis weak positive correlation
 • Retrospective studies, not longitudinal

- Toxic family environment? A bit stronger correlation

• Dominant, intrusive, overbearing parents
• Poor conflict resolution
• Emphasis on dieting and thinness. More than the others
• Fathers described as emotionally cold

3.5. Treatment

3.5.1. Inpatient

- Anorexia: below 70% of body weight

• Involuntary hospitalization not uncommon

• First goal. Restore weight level (tube feeding, if needed + rigorous control of
eating schedule)

• Antidepressant and even neuroleptic medication sometimes used (but little

specific evidence)

- Surprisingly few studies of outpatient anorexia treatments

• Study compared CBT to nutritional counseling
- CBT similar than for bulimia
- Nutritional counseling.
• Manual based treatment. Nutrition, education and food
exchanges
• Focused on meal planning and making sure they are eating a
healthy diet

- Both. 50 weekly sessions delivered for one year after hospitalization for anorexia

- Goals. Try to maintain any gains that they were able to achieve during inpatient treatment
and trying to avoid relapse during that year long period

3.5.2. RCT Results

- Time to relapse was faster in nutritional counseling than CBT group

• By the end of the 50 week, 80% had relapsed vs 25% for CBT

- First study to document therapeutic efficacy for any post-hospital treatment of anorexia, N
= 33 (small sample)
• We take it cautiously

4. Obesity

4.1. Terms

- Not in the DSM, but one of the biggest public health problems in the world.
• Overweight. Excess of body weight compared to set standards
• Obesity. Abnormally high proportion of body fat
• Can be overweight without being obese, but if overweight by definition also obese

- Most common measure of obesity is BMI

 • Based on ratio of height to weight
• Not gender specific

4.2. BMI

Used as a predictor if health worldwide.

http://www.nhlbisupport.com/bmi/

Pb. Does not take into account body types or physiques.

4.3. An alternative: Waist-Hip Ratio

- Takes the circumference of your waist to the circumference of your hips

- Distribution of fat may be most critical for predicting health than total weight

- Belly fat appears to be particularly important to predict health outcomes, which the WHR
takes into account

- Current guidelines. Ideally, WHR < 0.8 for women, < 1.0 for men
• Associated with reproductive functioning, health (diabetes, heart attack, stroke)

• Comparisons of WHR and BMI often find that WHR is better predictor of health
outcomes

4.4. Prevalence
Obesity is relatively prevalent in the US. Using BMI, what percentage of the population is
overweight.
- 2/3 of the population in the US
- About 40% meets criteria for obesity

2015-2016. Rates continue to be high, particularly in people above 40 years old. Consistent for men
and woman.
The trend in obesity is increasing over time in both adults and youth.
- Adults. From 30 to 40%
- Youth. From 14 to 18.5%

Common throughout the US.

- Areas in green and yellow = lower range
- Red and orange. High rate
- All states at least 20% obesity

There were a couple states like Hawaii, Colorado and the District of Columbia that had 20-25% of
obesity. Some of the lower rates

In the South and Midwest they tend to have higher rates of obesity.

4.5. Sleep
Study. Looked at mice that had a disrupted biological clock. They had one version of this clock gene
that is responsible for following your circadian rhythms that was disrupted for one group. They did
not sleep as consistently.

- Faulty internal clock can alter body’s metabolism

- Evidence from mice with disrupted biological clock

• Regular diet 35% increase in weight

• Fatty diet produced 75% increase in weight. It was the interaction between this
disrupted biological clock combined with a fatty diet that led to weight gain.

• Slept less and ate more!

• May be related to a decrease in the production of appetite-regulating

hypothalamic peptides.

 A disruption in the circadian rhythms may play an important role in weight gain. Important
to sleep to maintain a healthy weight.

4.6. Mortality

- Obese people have 50 to 100% increased risk of all causes mortality (= dying from any
cause)

- Life expectancy of a moderately obese person could be shortened 2 to 5 years

- Life expectancy of 20- to 30-year-old white male with BMI > 45 is shortened by 13 years

4.7. Fitness, not Fatness?

Is the weight that puts someone at risk for these negatives outcomes or is it the lack of fitness that
is associated with weight?
- Overweight is associated with poor outcomes, but is this due to poor fitness?
• Aerobics Center Longitudinal Study.
- Assess somebody’s BMI and assess their physical fitness

- They did it rigorously with a treadmill test. How long can you go on it as it
goes faster and steeper

- 25 000 men followed for 10-15 years

• Fitness better predictor of all-cause mortality rate than BMI in 25,000 men

• Better fit and fat than unfit and skinny? Probably.

• Unfortunately, a parallel study has not been completed in women

Another smaller study.

- They didn’t measured fitness with a physical exercise, but they asked people about their
physical fitness with a systematic self-reporting rating scale.

- Measure BMI

- Follow 1 000 woman for 4 years

- Looked at predicting negative health outcomes, not mortality

- Results

• Similar to the study with the men, women with low fitness had the highest risk of
negative health outcomes regardless of BMI category

• Not much difference between obese and not obese, but important between fit
and not fit

Women with low fitness had the highest risk of all negative health outcomes regardless of BMI
category.

4.8. Treatment
 - Americans spend $33 billion annually on weight-loss products and services
• All efforts at weight loss or weight maintenance including low-calorie foods,
artificially sweetened products such as diet sodas, and memberships to
commercial weight-loss centers

• Treatment can be very challenging and moderately successful, get more successful
as It gets more intensive but can get invasive

• Stepped care approach to treatment

• Exercise is not that efficient in weight loss unless you do a lot

• Most critical for weight loss is diet

4.8.1. Bariatric Surgery

Becoming increasingly popular in the US

- Early 90s. Rare

- Starting in the 2000s it became more common to the point where they’re about a little
over 200 000 bariatric surgeries performed every year

- Challenge. There are complications whenever there is any kind of surgery

Overall goal. Reduce the size of the stomach. Couple different ways to do it
- Bypass a portion of the stomach

- Gastric banding approach (less invasive). You insert a lap band and it restricts the food
intake to the stomach. It remains the original size, but it’s the amount of food that can get
into the stomach that is restricted. If someone eats too much, the food will go back up

The amount of weight can be between 30-50%.

Study. Are they able to keep this way down over time?
- People that received gastric bypass surgery or a version of it. (2 000 people)

- Looked at outcomes and compared with people that didn’t receive any surgical
intervention for weight loss, but received other kind of weight loss interventions (5 000
controls)

- Results.
• Dramatic weight loss after surgery. 30% reduction in their weight within 1 year of
the gastic bypass surgery.

• Control. Loss about 10%

 • Over the course of 10 years the weight remains pretty stable

 Fairly effective treatment with a sustained benefit.