Eating Disorders

Eating Disorder Statistics

• 30 million Americans suffer from an eating disorder • The rate of development of new cases of eating

disorders has been increasing since 1950 (Hudson et al., 2007; Streigel-Moore & Franko, 2003; Wade et al., 2011).

• There has been a rise in incidence of anorexia in young women 15-19 in each decade since 1930 (Hoek& van Hoeken, 2003).

• The incidence of bulimia in 10-39 year old women TRIPLED between 1988 and 1993 (Hoek& van Hoeken, 2003).

Risk factors for Eating Disorders

• they often occur with one or more other psychiatric disorders, which can complicate treatment and make recovery more difficult.

• Among those who suffer from eating disorders: – Alcohol and other substance abuse disorders are 4 times

more common than in the general populations (Harrop & Marlatt, 2010).

– Depression and other mood disorders co-occur quite frequently (Mangweth et al., 2003; McElroy, Kotwal, & Keck, 2006).

– There is a markedly elevated risk for obsessive- compulsive disorder (Altman & Shankman, 2009).

Biological risk factors

• Scientists are still researching possible biochemical or biological causes of eating disorders. Current research indicates that there are significant genetic contributions to eating disorders. (NEDA, 2017) – In some individuals with eating disorders, certain

chemicals in the brain that control hunger, appetite, and digestion have been found to be unbalanced. The exact meaning and implications of these imbalances remain under investigation.

– Eating disorders often run in families.

Diagnosing Anorexia Nervosa (APA, 2013)

• Anorexia nervosa is a mental health disorder characterized by distorted body image and excessive dieting that leads to severe weight loss with a pathological fear of becoming fat. – Females- more likely to focus on weight loss – Males- more likely to focus on muscle mass

• Diagnostic criteria – restriction of calorie intake resulting in a below normal body

weight level for age and height

Diagnosing Anorexia Nervosa (APA, 2013)

• There are Two subtypes of AN: 1. Restricting type: a reduction in total food intake without binge-

eating or purging behavior 2. Binging eating/purging type: regularly engaging in self-induced

vomiting or the misuse of laxatives, diuretics, or enemas 3. Can also be characterized by a combination of the 2:

• An individual with anorexia has an appetite; he/she just tries to control it. It is very difficult when a person is starving not to want to eat. What happens to many individuals is that they lose control

• Other characteristics – significant disturbance in the perception of the shape or size of his or

her body – exercising compulsively – developing unusual habits such as refusing to eat in front of others

Diagnosing Bulimia Nervosa (APA, 2013)

• A serious, potentially life-threatening mental health disorder characterized by:

1. frequent episodes of binge eating. . . • eating, in a short period of time (e.g., within any 2-hour period),

an amount of food that is definitely larger than most people would eat during a similar period of time and under similar circumstances

AND • a sense of impaired control over eating during the episode (e.g.,

a feeling that one cannot stop eating or control what or how much one is eating)

2. . . .followed by inappropriate compensatory behaviors, such as self-induced vomiting, to avoid weight gain.

• On average, episodes must occur at least once a week for 3 months.

Diagnosing a Binge Episode (APA, 2013)

• Indicators of impaired control – eat too quickly, even when he or she is not hungry – feelings of guilt, embarrassment, or disgust after overeating – eat alone to hide the behavior because of embarrassment

over how much one is eating – eating until feeling uncomfortably full – eating large amounts of food when not hungry

• Types of compensatory behaviors following a binge eposode – Purging:

• self-induced vomiting; misuse of laxatives, diuretics or enemas – Non-purging:

• use of medications, fasting, or excessive exercise

Diagnosing Bulimia Nervosa (APA, 2013)

• Increased frequency of depressive symptoms and Mood Disorders (particularly Dysthymic Disorder and Major Depressive Disorder)

• Self-evaluation is unduly influenced by body shape and weight, but individuals typically are within the normal weight range, although some may be slightly underweight or overweight

• The disturbance does not occur exclusively during episodes of AN.

Comparison of AN and BN

• Common Causes: – “The etiology of AN and BN is presumed

to be complex and multiple, influenced by developmental, social, and biological processes the exact nature of which remain poorly understood.” (Treasure and Campbell, 1994)

Comparison of AN and BN (APA, 2013)

• Common characteristics – Both are NOT about food

• Food is an instrument, not a cause. Both have more to do with

– deep social, psychological and emotional issues – profound feelings of lack of control – Brain chemistry

• Different Characteristics – AN individuals- resistance to maintaining body

weight at or above a minimally normal weight for age and height

– BN Individuals- typically are within the normal weight range for their age and height

Prevalence of Anorexia Nervosa and Bulimia Nervosa (APA, 2013)

• Prevalence – Most common in young adolescent females

between 15 and 19 years old – 7 % of all cases are male – Occurs more frequently in industrialized

societies, in which • there is an abundance of food • being considered attractive is linked to being thin,

especially for females Immigrants from cultures in which the disorder is

rare who emigrate to cultures in which the disorder is more prevalent may develop Anorexia Nervosa as thin-body ideals are assimilated.

What is Binge Eating Disorder? (APA, 2013)

• Binge eating disorder is a mental health disorder defined as recurring episodes of eating significantly more food in a short period of time than most people would eat under similar circumstances, with episodes marked by:

– feelings of lack of control – eat too quickly, even when he or she is not hungry – feelings of guilt, embarrassment, or disgust – may binge eat alone to hide the behavior. – distress

• Episodes must occur, on average, at least once a week over three months.

Prevalence of Binge Eating Disorder

• Most common in the obese (BMI >30) and severely obese (BMI >40) – Of those who seek professional treatment for obesity, 1/5 meet the

criteria for BED. • obese with binge eating disorder

– often became overweight at a younger age than those without the disorder

• About 2 percent of all adults in the United States (as many as 4 million Americans) have binge eating disorder – 10 to 15 percent of people who are mildly obese and who try to lose

weight on their own or through commercial weight-loss programs have binge eating disorder

• As many as half of all people with binge eating disorder have been depressed in the past. – Whether depression causes binge eating disorder or whether binge

eating disorder causes depression is not known for sure.

Health Consequences of Eating Disorders

(Casiero & Frishman, 2006)

Anorexia Nervosa Binge Eating Disorder Bulimia Nervosa Cardiac Complications: Arrhythmia, Hypotension, Bradycardia, Low cardiac output. These can lead to severe fatigue and syncope

Cardiac Complications: High BP, High cholesterol, High triglycerides, etc.

Cardiac Complications:

cardiac arrhythmias, cardiac myopathy

Other organs: Dehydration leading to kidney failure, amenorrhea, osteoporosis, muscle loss psychological/cognitive dysfunction due to malnutrition

Other organs: Type II diabetes, Gallbladder disease, etc.

Other organs: Gastric rupture Inflammation and/or tears of the esophagus electrolyte imbalance due to dehydration , constipation, irritable bowel syndrome, Pancreatitis, skeletal myopathies, peptic ulcers

Ingestion/digestion: Re-feeding Syndrome: reintroduction of food too quickly, most often in those who are severely malnourished. Associated with: Tachycardia, Congestive heart failure, Sudden cardiac death

Ingestion/digestion: malnutrition

Ingestion/digestion: Tooth decay and staining, malnutrition

Cosmetic Complications: Lanugo (Downy hair all over body), Hair loss, Dry skin

Other Complications: morbid obesity, major anxiety and depressive disorders

Athletes and Eating Disorders (Insel & Roth, 2016)

• Athletes most at risk – Individual sports vs. team sports

• Gymnasts, Body builders, Wrestlers, Jockeys (avg weight = 110 lbs), Dancers

– Training for a sport since childhood – Being an elite athlete – Endurance sports

• Rowers, Runners, Swimmers

Women Athletes and Eating Disorders (Insel & Roth, 2016)

Female Athlete Triad (Insel & Roth, 2016)

• Premature Osteoporosis – Amenorrhea has been found to cause bone

densities equivalent to females in their 60s – Young amenorrheic women may lose as much as

2% to 6% of bone mass each year. – Over time, an athlete in her twenties could lose

as much as 25% of her bone density

Treating Eating Disorders

Treating Eating Disorders (APA, 2006)

• Treatment is considered multimodal and multidimensional – Individual, group, and/or family counseling – Possible in-patient hospitalization – Behavioral and/or cognitive therapy

• Medications e.g. anti-depressants or appetite stimulators have NOT been shown to be successful in initial treatment

Recovery from AN (APA, 2006) • Goal of recovery: to restore patient to normal

weight: BMI >17.5 kg/m2 – Immediate weight gain either through outpatient care or

hospitalization • Restore Normal menstruation • Treat physical complications.

– Medications, calcium and vitamin D effectively reverse the degree of osteoporosis in patients with anorexia nervosa

• Prevent relapse. • After patients have gained weight and when the psychological effects

of malnutrition are resolving, preliminary evidence suggests that antidepressants may be helpful with weight maintenance.

• Minimize food restrictions. • Encourage healthy but not excessive exercise.

Recovery from AN (APA, 2006) • Method of recovery

– Enhance the patient’s motivation to cooperate and participate in treatment. – Provide education about healthy nutrition and eating patterns. – Psychotherapy for underlying psychosocial factors

• Treat associated psychiatric conditions, including defects in mood regulation, self- esteem, and behavior.

• Correct core maladaptive thoughts and attitudes. • Enlist family support and provide family counseling and therapy where appropriate.

• Recovery is considered stable when: – BMI >17.5 kg/m2 for at least one year

• Early onset of medical care = good prognosis • Delayed or insufficient medical care = poor prognosis

Recovery from BN (APA, 2006)

1. Reduce binging and purging behavior.

Goals of recovery: 2. Address underlying themes: – Developmental issues – Identity formation – Body image concerns – Self-esteem in areas outside

weight and shape – Difficulties with sexual issues

and aggression – Affect regulation – Gender role expectations – Family dysfunction – Coping styles

AN: The current picture of recovery (UMMC, 2015)

• The outlook for people with anorexia is variable, with recovery often taking between 4 to 7 years. Long-term studies show that: – 50 to 70% of people recover from anorexia nervosa. – 25% never fully recover.

• There is also a high chance of relapse even after recovery. • More people die from anorexia than from any other psychiatric

disorder. Anorexia is associated with high lifetime mortality from both natural and unnatural causes: – Up to 20% die from complications of the disease. – suicide is responsible for 50% of fatalities associated with anorexia

• Many, even after they are considered “cured,” continue to show traits of anorexia, such as remaining very thin and striving for perfection.

BN: The current picture of recovery

– Recovery from Bulimia Nervosa – 50% recover – 30% improve – 20% don’t recover – 10% continue to meet full diagnostic criteria after 10

years of the illness

Treatment Research Shows Hopeful Success

• Cognitive Behavioral Therapy (CBT) for Bulimia Nervosa patients (DeAngelis, 2002) – works with the unrealistically negative thoughts people

with bulimia nervosa have about their appearance – guides them in changing eating behaviors

• Example: helping them normalize their diet. – Research:

• Immediately after Cognitive Behavioral Therapy treatment, a significant number of cognitive behavioral therapy patients:

– stopped bingeing and purging – showed positive changes in psychosocial eating-disorder symptoms

such as preoccupation with shape and weight, depression and self- esteem

Treatment Research Shows Hopeful Success

• Anorexia Nervosa – A new outpatient treatment from England is showing

great promise as an effective option for AN. – Psychologists use a form of family therapy that enlists

parents’ aid in getting their child to eat again and helps to strengthen the child’s autonomy.

• the method targets the obsessive anorexic mindset as the villain rather than the patient or their family.

– “This approach sees the eating disorder as controlling the adolescent, thereby interrupting normal development. The family is not to blame for the eating disorder, but is seen as a valuable ally in treatment.” (Le Grange)

• Results: – two-thirds of all patients regained weight within a normal range

without needing to be admitted to the hospital – most showed striking improvements in psychological functioning – parents became less critical of each other and of their child by the end

of treatment.

Treatment Research Shows Hopeful Success (Bergh, et. al., 2013)

• Subjects- – 1,428 patients with eating disorders treated at 6 clinics that were consecutively referred

over 18 years – Patients had used both inpatient and outpatient treatment. – Patients were diagnosed with anorexia nervosa, bulimia nervosa, or an eating disorder not

otherwise specified. • Treatment-

– the patients normalize their eating pattern with mealtime feedback provided by a Mandometer

• A scale that rests under a dinner plate, connected to a small computer with a monitor. Allowed patients to:

– compare their rate of eating in real time to that of a typical person eating that meal – develop normal feelings of satiety

• Initially, a behavioral therapist assisted the patients with the use of the Mandometer, but the patients got used to the procedure rapidly and practiced eating without the support of a therapist, including practicing at home.

– patients were provided with warmth, using warm rooms (temperature can be set at 40°C), or thermal blankets, or jackets, to calm them and to avoid the use of calories for thermoregulation.

– physical activity was restricted to calm them and avoid the use exercise for thermoregulation

– A great deal of time was spent convincing and coaxing the patients to start resuming their normal social interactions.

Treatment Research Shows Hopeful Success (Bergh, et. al., 2013)

• Results – The estimated rate of remission for this therapy was

75% after a median of 12.5 months of treatment. – Of those who went in remission, the estimated rate

of relapse was 10% over 5 years of follow-up and there was no mortality.

– These data replicate the outcomes reported in our previous studies and they compare favorably with the poor long-term remission rates, the high rate of relapse, and the high mortality rate reported with standard treatments for eating disorders.

Recovery from BED (APA, 2006) Goal of recovery:

1. Reduce binge eating behaviors 2. facilitate weight loss

• Nutritional rehabilitation and counseling • Psychosocial treatment

– Group and individual psychotherapy, guided self-help and support groups that use a “non-diet” approach and focus on self-acceptance, improved body image, better nutrition and health, and increased physical movement

• Medications – Weight Loss meds

• The appetite-suppressant medication sibutramine is effective for binge suppression, at least in the short term, and is also associated with significant weight loss

Recovery from BED (APA, 2006) • Weight Loss:

– Very-low-calorie diets • have been associated with substantial initial weight

losses – 1 year after treatment: >33% of patients maintaining their

weight loss Greater than 1 year after treatment: weight regain is common

– Medications: • sibutramine was shown to have significant beneficial

effects on binge eating behavior and weight loss – weight decrease 7.4 kg, medication group – weight increase of 1.4 kg, placebo group

Recovery from BED (APA, 2006) • Reduction of binge eating behaviors

– psychotherapy • Has been associated with

– binge frequency reduction rates of 67% or more – significant abstinence rates during active treatment Deterioration during the follow-up period has been observed with all

forms of psychotherapy

– Guided Self-help programs • have been effective in reducing the symptoms of binge eating

disorder in the short run for some patients

– Lifestyle treatment approach • Those focused on self-acceptance and a healthy lifestyle rather

than weight loss may reduce binge eating behavior, depression, anxiety and body dissatisfaction, while improving physical health and quality of life


• •

References • APA. (2013). Eating Disorders. DSM-5-TR® Diagnostic and

Statistical Manual of Mental Disorders 5th Edition. Arlington, VA: American Psychiatric Publishing, Inc.

• APA. (2006) Treatment of Patients With Eating Disorders, 3rd Edition. American Psychiatric Association Practice Guidelines. Arlington, VA: American Psychiatric Publishing, Inc.

• Bergh, C. et. al. (2013). Effective Treatment of Eating Disorders: Results at Multiple Sites. Behavioral Neuroscience. V127; N6, 878 – 889.

• Casiero, D. & Frishman, W.H. (2006). Cardiovascular complications of eating disorders. Cardiol Rev, 14(5), 227-231.

• DeAngelis, T. (2002). Promising treatments for anorexia and bulimia: Research boosts support for tough-to-treat eating disorders. Monitor on Psychology. V33; No. 3.

• Hoek, H. W., & van Hoeken, D. (2003). Review of the prevalence and incidence of eating disorders. International Journal of Eating Disorders, 34(4), 383-396.

References • Hudson J. I., Hiripi E., Pope H. G. Jr., & Kessler R. C. (2007). The

prevalence and correlates of eating disorders in the National Comorbidity Survey Replication. Biological Psychiatry, 61, 348-358.

• Insel, P.M. & Roth, W.T. (2016). Core Concepts in Health; 15th Ed.: Chapter 10. New York: McGraw-Hill.

• National Eating Disorders Association (NEDA). (2017). Factors that may contribute to eating disorders. Available at eating-disorders Accessed on August 30, 2017.

• Streigel-Moore R. H., & Franko D. L. (2003). Epidemiology of binge eating disorder. International Journal of Eating Disorders, 34, S19-S29

• Treasure J, Campbell I: The case for biology in the aetiology of anorexia nervosa. Psychol Med 24:3–8, 1994

• University of Maryland medical center (UMMC). (2015). Anorexia Nervosa. Available at a-nervosa. Accessed on August 30, 2017)

• Wade, T. D., Keski-Rahkonen A., & Hudson J. (2011).Epidemiology of eating disorders. In M. Tsuang and M. Tohen (Eds.), Textbook in Psychiatric Epidemiology (3rd ed.) (pp. 343-360). New York: Wiley

  • Eating Disorders
  • Eating Disorder Statistics
  • Risk factors for Eating Disorders
  • Biological risk factors
  • Diagnosing Anorexia Nervosa �(APA, 2013)
  • Diagnosing Anorexia Nervosa�(APA, 2013)
  • Diagnosing Bulimia Nervosa �(APA, 2013)
  • Diagnosing a Binge Episode �(APA, 2013)
  • Diagnosing Bulimia Nervosa �(APA, 2013)
  • Comparison of AN and BN
  • Comparison of AN and BN�(APA, 2013)
  • Prevalence of Anorexia Nervosa and Bulimia Nervosa (APA, 2013)
  • What is Binge Eating Disorder?�(APA, 2013)
  • Prevalence of Binge Eating Disorder
  • Health Consequences of Eating Disorders�(Casiero & Frishman, 2006)
  • Slide Number 16
  • Athletes and Eating Disorders �(Insel & Roth, 2016)
  • Women Athletes and Eating Disorders (Insel & Roth, 2016)
  • Female Athlete Triad (Insel & Roth, 2016)
  • Treating Eating Disorders
  • Treating Eating Disorders (APA, 2006)
  • Recovery from AN (APA, 2006)
  • Recovery from AN (APA, 2006)
  • Recovery from BN (APA, 2006)
  • AN: The current picture of recovery�(UMMC, 2015)
  • BN: The current picture of recovery
  • Treatment Research Shows �Hopeful Success
  • Treatment Research Shows �Hopeful Success
  • Treatment Research Shows �Hopeful Success (Bergh, et. al., 2013)
  • Treatment Research Shows �Hopeful Success (Bergh, et. al., 2013)
  • Recovery from BED (APA, 2006)
  • Recovery from BED (APA, 2006)
  • Recovery from BED (APA, 2006)
  • Resources
  • References
  • References