Eating Disorders

Dr Evelyn Smith
 Eating disorders…

….are the deadliest mental illnesses.

longitudinal study (Crow, et al., 2009) showed crude

mortality rates of:
4% for AN patients
3.9% for BN patients
5.2% for EDNOS patients.
 Eating disorders
• 1-2% of the population has an eating disorder;
20-30% suffer from eating disorder symptoms
• Types defined by the DSM-V (American
Psychiatric Association, 2013)
• Pica
• Rumination Disorder
• Avoidant/Restrictive Food Intake Disorder
• Anorexia nervosa
• Bulimia nervosa
• Binge eating disorder
• Other specified feeding or eating disorder (OSFED)
Anorexia nervosa
 Anorexia Nervosa - outline
• Case example
• DSM-V criteria
• Consequences
• Treatment
Rachel and Clare
 Rachel and Clare

• We sleep in beds side by side but lately Rachel’s been waking

up in my bed, because it’s been cold. Often Rachel will have
been up half the night. We’re perfectionists who like to clean
everything. Breakfast is the same as lunch and dinner: some
melon and a cup of coffee, if we manage to keep that down.
Everything we eat and do has to be exactly the same. Every
day we walk four kilometers to town to get our medication for
the pain of our osteoporosis. Then we’ll walk home. - Clare
 DSM-V Criterion A

• Restriction of energy intake relative to

requirements, leading to a significantly low body
weight in the context of age, sex, developmental
trajectory, and physical health.
• Underweight: BMI (kg/m2) of <=18.5
• weight loss leading to maintenance of body weight
less than 85% of that expected
• Weight loss is voluntary
 DSM-V Criterion B

• Intense fear of gaining weight or becoming fat, or

persistent behavior to avoid weight gain, even
though underweight.
• Most have never been overweight
 DSM-V Criterion C

• Disturbance in the way in which one's body weight

or shape is experienced, undue influence of body
weight or shape on self-evaluation, or persistent
lack of recognition of the seriousness of the
current low body weight.
 Subtypes of AN

• Restricting Type: the person does not regularly

engage in binge eating or purging behavior (i.e.,
self-induced vomiting or the misuse of laxatives,
diuretics, or enemas)

• Binge-Eating/Purging Type: the person regularly

engages in binge eating or purging behavior.
 Treatment

• Refeeding
• Motivational interviewing
• Behaviour Therapy
• Cognitive Behavioural Therapy
• Cognitive Remediation Therapy
• Interpersonal Psychotherapy
• Maudsley Therapy
• Medication
 Bulimia nervosa - outline
• Prevalence
• DSM-V criteria
• Consequences
• Treatment

• Criticisms of the model and treatment

 Bulimia nervosa

• Prevalence
• Primarily affects females
• 1-3% lifetime prevalence
• Age of onset and course of the disorder
 DSM-V Criterion A

• Recurrent episodes of binge eating. An

episode of binge eating is characterized by
both of the following:
• (1) eating, in a discrete 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
• (2) a sense of lack of control over eating during the
episode (e.g., a feeling that one cannot stop eating
or control what or how much one is eating)
 DSM-V Criterion B

• Recurrent inappropriate compensatory behaviors in

order to prevent weight gain, such as self-induced
vomiting; misuse of laxatives, diuretics, enemas, or
other medications; fasting or excessive exercise.
 DSM-V Criterion C

• The binge eating and inappropriate compensatory

behaviors both occur, on average, at least once a
week for 3 months.
 DSM-V Criterion D

• Self-evaluation is unduly influenced by body shape

and weight.
 DSM-V Criterion E

• The disturbance does not occur exclusively during

episodes of Anorexia Nervosa.
Bulimia nervosa
Cognitive model for bulimia
nervosa (Fairburn,1986, 1997)
 Evidence that dieting does
cause binge eating
• Evidence for this relationship:
• Key’s starvation study
• Prospective studies
• Correlational studies: Wilson, et al. (2002) showed that
a decrease in dieting in eating disorders patients
undergoing cognitive behavioral therapy (CBT) was
associated with a reduction in binge eating.
Evidence that dieting does
not predict binge eating
• Review article (Smith, accepted)
• 26 studies reviewed
• Dieting interventions
• if dieting causes bingeing, individuals who begin a
dieting program should subsequently increase their
frequency of binge eating.
Evidence that dieting does
not predict binge eating

• Normal weight, overweight and obese

samples: Randomized controlled trials to a
weight loss low-calorie diet versus a
waitlist control group resulted in a decrease
in weight and binge eating for obese and
overweight adults (14 studies)

• Binge eating disorder: 12 studies

 Evidence that dieting does
not predict binge eating

• Bulimia nervosa (1 study): Burton and Stice (2006) randomly

allocated 85 individuals suffering from bulimic symptoms to a
dieting program run weekly for six weeks or to a waitlist
control condition. Participants in the dieting program had a
significant reduction in binge eating and compensatory
behaviors and a slight reduction in weight, and this was
maintained at 3-month follow up.
• effect size for the reduction in binge eating was comparable
to the effects of CBT (i.e. healthy diet: r=.50 versus CBT
r=.55), however, CBT is for an average of 20 sessions
whereas the healthy dieting program was only for 6 weeks!
Evidence that dieting does not
predict binge eating

• Fasting/Meal skipping - normal sample

• Groesz and Stice (2007) randomly allocated 160
overweight women to a Many Small Meals diet, a
Normal diet or a waitlist condition for six weeks.

• Skipping breakfast?

• Ramadan month fasting?

Evidence that dieting does not
predict binge eating
• Fasting/Meal skipping - eating disorder sample
• A study showed that nineteen hours of food deprivation was not
able trigger bingeing or marked overeating in 10 patients with
bulimia nervosa outpatient, 10 patients with bulimia nervosa
inpatient, or 10 patients with anorexia binge/purging type,
compared to restrained and non-restrained eaters (Hetherington,
Stoner, Andersen, & Rolls, 2000).

• Self report measurement of what comes first, dieting or binge

eating?
 Bulimia nervosa

Treatment
• Motivational enhancement therapy (MET)
• Dialectical behavioural therapy
• DBT combines cognitive behavioural techniques with
distress tolerance, mindfulness exercises and interpersonal
training.
• Pharmacological approaches
• Antidepressant medication is more effective than placebo
• Fluoxetine (Prozac) is FDA-approved for bulimia
• Cognitive behavioural therapy
• Interpersonal psychotherapy
• Help individuals identify and change interpersonal problems
Binge eating disorder - Outline

• Epidemiology of BED
• Binge eating disorder DSM-V criteria
• Aetiology of BED
• Maintenance of BED
• Treatment of BED
 Binge eating disorder (BED)
• Epidemiology
• Prevalence
• 2/3 female
• 3-5% lifetime prevalence

• Age of onset and course of the disorder

• Age of onset is unknown, estimated to be late adolescence and
young adulthood
• Course is controversial, some suggest it is a short-term condition
while others argue it is more chronic
 DSM-V Criterion A

• A. Recurrent episodes of binge eating. An

episode of binge eating is characterized by
both of the following:
• 1. eating, in a discrete period of time (e.g., within
any 2-hour period), an amount of food that is
definitely larger than most people would eat in a
similar period of time under similar circumstances
• 2. a sense of lack of control over eating during the
episode (e.g., a feeling that one cannot stop eating
or control what or how much one is eating)
 DSM-V Criterion B

• B. The binge-eating episodes are associated

with three (or more) of the following:
• 1. eating much more rapidly than normal
• 2. eating until feeling uncomfortably full
• 3. eating large amounts of food when not feeling
physically hungry
• 4. eating alone because of being embarrassed by
how much one is eating
• 5. feeling disgusted with oneself, depressed, or
very guilty after overeating
 DSM-V Criterion C

• C. Marked distress regarding binge eating is present.

 DSM-V Criterion D
• D. The binge eating occurs, on average, at least
once a week for three months.
 DSM-V Criterion E

• E. The binge eating is not associated with the

recurrent use of inappropriate compensatory
behavior (i.e., purging) and does not occur
exclusively during the course of bulimia nervosa or
anorexia nervosa.
 Treatment
 Self-help approaches
• Pure self help and guided self-help both may be efficacious
 CBT
• Develop a moderate eating plan
• Increase physical activity
• Achieve greater acceptance of body shape and weight
• Overcoming barriers for change
 Interpersonal psychotherapy (IPT)
• Highly effective in reducing binge eating and as effective as
CBT
 Behavioural weight loss
• Emphasis is on weight loss by restricting caloric intake and
increasing activity
 Pharmacological approaches
• Antidepressant medications have been supported, although
not as effective as CBT
CBT VS IPT