Eating disorders and body image

Dr. Gema Simbee

Psychiatrist
 Overview

• Definition
– diagnoses
– transdiagnostic approach
• Incidence and prevalence
• Causes and maintaining factors
• Models of the eating disorders
• Treatments and outcomes
• Body image

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 DIAGNOSIS AND CLASSIFICATION

• ‘True Eating Disorder’ – grossly disordered

or chaotic eating behaviour associated with
morbid preoccupation with body weight and
shape (irrespective of weight)

• Eating difficulty / problem – not associated

with clinically significant functional or
developmental impairment
 DSM ΙV vs ICD10 CLINICAL EATING
DISORDERS
DSM ΙV (Amer Psych Assoc1994)
• AN restricting and binge-purge
subtypes
• BN purging and non-purging
subtypes
• EDNOS (clinically severe but does
not meet criteria for AN, BN)
• Feeding disorder of infancy or
early childhood (onset before 6
years)
• Pica
• Rumination disorder
ICD 10 (WHO 1992)
• AN
• BN
• Atypical AN and atypical BN
• Other :
- Overeating associated with other
psychological disturbances
- Vomiting associated with other
psychological disturbances
- Other eating disorders
- Eating disorder, unspecified
• Feeding disorder of infancy and
childhood
• Pica of infancy and childhood
 Diagnosis (DSM-IV, 1994)

• Anorexia nervosa
– A. Refusal to keep body weight above minimal
healthy level (e.g., 85% of expected weight)
– B. Fear of weight gain
– C. Disturbance of body experience
– D. Amenorrhea x 3 consecutive cycles (or
comparable hormonal disturbance)

• Subtypes
– restricting
– binge-eating/purging subtypes
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 Diagnosis (DSM-IV, 1994)

• Bulimia nervosa
– A. Recurrent episodes of binge-eating
• (large amount of food; sense of lack of control)
– B. Compensatory behaviours
• (vomiting, diuretics, laxatives, speed, fasting, exercise)
– C. Bingeing & compensation happen twice per
week over at least 3 months
– D. Self-evaluation is unduly influenced by body
shape & weight
– E. Not simply a phase of anorexia
• Purging and non-purging subtypes
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 Diagnosis (DSM-IV, 1994)

• Eating Disorders Not Otherwise Specified

(EDNOS)
• Atypical bulimia nervosa
• Atypical anorexia nervosa
• Binge eating disorder
• Chew and spit
• Purging disorder
• Disorders more common in child cases
– food avoidance emotional disorder
– food faddiness

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 Other Eating Disorders

• Rumination Disorder
– Chronic regurgitation and reswallowing of partially
digested food
– Most prevalent among infants and persons with
mental retardation
• Pica
– Repetitive eating of inedible substances
– Seen in infants and persons with severe
developmental/intellectual disabilities
– Treatment involves operant procedures
 Other eating disorders
• Feeding Disorder
– Failure to eat adequately, resulting in
insufficient weight gain
– Disorder of infancy and early childhood
– Treatment involves regulating eating and
family therapy

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 What do we know about current diagnostic
categories?
– It does not do what it should
• 40-50% of cases do not fit neatly into
diagnoses
• atypical cases (EDNOS) are the largest
group, & they are comparable in severity to
BN (Fairburn et al., 2007)
• many fail to stay in one diagnosis (Milos et
al., 2005)

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 DSM V

• Change should be conservative to minimise

disruption & potential loss of established
knowledge
• Current limitations, e.g.
– Amenorrhea
– Criteria – such as twice weekly bingeing for BN
– Binge eating disorder
• Two EDNOS subgroups (Fairburn)
– Those that closely resemble AN/BN but just fail to
meet criteria
– ‘Mixed’, in which clinical features are present but
combined in a different way to AN/BN
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 DSM V – potential solutions
• Fairburn & Bohn (2005) 3 potential solutions;
• Relax the diagnostic criteria for AN & BN
– Drop amenorrhea criteria
– ‘core psychopathology’ redefined to include o/e of
controlling eating without shape/weight concerns
• Reclassifying EDNOS
– A new diagnostic category ‘mixed ED’
• The transdiagnostic solution
– Create a single unitary ED diagnostic category

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 Transdiagnosis
• Some have proposed a shift away from
rigid diagnoses
– transdiagnostic model (Waller, 1993; Fairburn et
al., 2003)
– focus on symptoms and cognitions
• Some argue that anorexia is a distinct
illness and should be treated so
– Cognitive interpersonal model (Schmidt &
Treasure)
– Palmer, Touyz
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 Incidence and prevalence
How common are the eating disorders?
• All figures are taken from westernized cultures
– similar across countries

• Peak age of onset is slightly younger in

anorexia
– 14-16 years vs 18-20 years
– but many cases are younger or older

• Female: male ratio

– approximately 20:1
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How common are the eating disorders?
Prevalence
• Number of cases in the population at any one
time
• Anorexia nervosa
– 0.5-1.0% of teenage girls

• Bulimia nervosa
– 1-2% of women aged 16-35

• EDNOS
– 2-3% of women aged 16-35
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How common are the eating disorders?
Incidence
• Number of new cases in a year
• Anorexia nervosa
– 21 new cases per 100,000 population

• Bulimia nervosa
– 30 new cases per 100,000 population

• EDNOS
– Similar to bulimia nervosa?
– not known yet
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 Causes and maintaining factors
• No single factor is implicated in the causation of
the EDs
• There are multiple factors that converge on two
key elements
– low self-esteem
– high levels of perfectionism

• These contribute to a need for control

– focused on eating, weight and shape
– due to psychosocial factors
• social/cultural expectations, media images, teasing, social
comparison with others appearance and behaviours, etc.

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 BIOPSYCHOSOCIAL MODELS OF
RISK AND MAINTENANCE
•Physical and nutritional status
•Temperament
•Self esteem,values,personal identity
•Emotional processing and literacy

SOCIAL
INDIVIDUAL
•Life events
•Peer relationships
•Media influence

Predisposing SYSTEMIC
•Genetic
Precipitating
•Family beliefs re weight,shape,
Perpetuating
eating
 Risk factors

General
• Western culture
• Female
• Adolescent/young adult

Biological
• Genetic predisposition?
– various findings, but none have been replicated

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 Risk factors

Family history of:

– Depression
– Substance/alcohol abuse
– Eating disorder
– Obesity
– Chronic dieting

Experiences
– Poor parenting (invalidating environment)
– Abuse
– Critical comments re eating, shape and weight
– Pressures to be slim (e.g., ballet, gymnastics)

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 Risk factors

Individual characteristics
– Low self-esteem
– Perfectionism
– Anxiety problems
– Obesity
– Early menarche

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 Treatment

• Physical needs are a priority

• Re-feeding for nutritional deficits
• Risk assessment
– Rapid course of weight loss
– High levels of purging

• Medication
– some impact of SSRIs on bulimic symptoms

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 What does NICE say?
NICE guidelines (2004)
• Anorexia nervosa
– Can consider Cognitive Analytic Therapy
(CAT), Cognitive Behaviour Therapy (CBT),
Interpersonal Therapy (IPT), focal
psychodynamic therapy & family interventions
• Bulimia nervosa
– Can consider guided self help (GSH), CBT-
BN, IPT.
• Binge eating disorder
– GSH, CBT-BED
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 Key issues in psychological
treatment of eating disorders
• Ambivalence & motivation
– To be expected due to ego-syntonic nature of
disorder
– Fluctuates throughout treatment
– Work with it, not against it
– Stage of Change Model
• Need for behavioural as well as cognitive
& emotional change
– Reduction in behaviours, normalisation of
weight
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 Key issues in psychological
treatment of eating disorders
• Over evaluation of eating, shape and
weight
– The core maintaining mechanism
– Needs to change to reduce risk of relapse

• Treating the person as an individual, not

just the eating disorder

• Change may be slow and individuals may

need more than one treatment episode 26
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 Treatment setting & format

• Out patient, day care (partial

hospitalisation), in patient
• Individual therapy or group work
• Self-help
– guided is better
– using technological developments
• internet, CD, text messages

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 Cognitive behaviour therapy (CBT)
• CBT focuses on the principle that our perception
of ourselves, the world & our future shape our
emotions and behaviour.
• Proposes that among people with psychological
disturbance (e.g., dep, anx, EDs), thinking is
often distorted or dysfunctional, leading to
distress & unhelpful behaviours.
• CBT works with individual to challenge & modify
thoughts and change behaviours.

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 Outline of CBT for the eating disorders
• Engagement
• Motivation
• Psychoeducation
• Formulation
• Self-monitoring
– food diaries; emotion diaries; regular weighing
• Cognitive restructuring
• Behavioural experiments
• Relapse prevention
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 MANTRA
• Maudsley Model of Anorexia Nervosa
Treatment for Adults
– Developed by Ulrike Schmidt & Janet
Treasure
• 20 session workbook based Rx
• Uses a motivational interviewing stance
• Covers risk management, formulation,
nutrition,
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 Specialist Supportive Clinical
Management (SSCM)
• Developed by Virginia McIntosh & NZ
team
• Combines features of good clinical
management & supportive psychotherapy
• Includes education, care and support
• Provides information on normal eating
habits and weight restoration.
• Sessions are patient led.
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Body Image

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 What is body image?
• ‘a person’s perceptions, thoughts, feelings and
behaviours about his or her body’
• Multi-faceted & interlinked
– What we see (perceptual)
– What we think (cognitive)
– How we feel (emotional)
– What we do (behavioural)
• Attitudes gathered throughout life and influenced
by others

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 What is body image
dissatisfaction?
• ‘a person’s negative thoughts and feelings
about his or her body’
• Usually involves a perceived discrepancy
between a person’s evaluation of his/her
body and their ideal body

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 Body image in the eating
disorders
• Disturbance is not always present or invariant

• Three types
• disturbance of body percept
– the patient sees a grossly distorted view of their body
• disturbance of body concept
– the patient may or may not have an accurate perception, but is
dissatisfied with what they see
• fear of fatness
– an image of the body as being potentially out of control, where
the patient is petrified of becoming overweight

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Cognitive behavioural treatment
of disturbed body image
• Assessment & formulation
• Psychoeducation
– Functions of the body
– Set point hypothesis
• Cognitive restructuring
– Cognitive challenging
– Behavioural experiments
• Practical steps
• Alternative perspectives
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Imagery 36