Anorexia Nervosa

Anorexia Nervosa

What is it?
1. Symptoms
  1. refusal to eat and maintain a minimum average expected body weight
  2. Fear of gaining weight or becoming fat
  3. Distorted perception of body weight and shape
  4. Amenorrhea
    1. absence of at least 3 consecutive menstrual cycles
  5. Weight less than 85% of expected
2. Prevalence
  1. 90% of cases are in females between 13 and 18 years of age
  2. rarely begins before puberty
    1. sometimes younger children can suffer from it
  3. DSM-IV states it occurs in 0.5-1% of females in adolescence and early adulthood
    1. DSM-V may be different
3. Course and Outcomes
  1. 20% have one episode and then recover
  2. 60% follow an episodic pattern of weight gain and relapse over a number of years
  3. Remaining 20% continue to be affected and often require hospitalisation
    1. Mortality rate of those admitted to hospital is over 10% due to starvation or suicide
Explanations
1. Biological
  1. Neurotransmitters
    1. Hypothalamus regulates eating
    2. Amino acids in food leads to serotonin production
      1. In someone without AN, they feel full with no anxiety
      2. In someone with AN, they're eating less
        the brain overcompensates for this by producing more serotonin
        therefore if the person with AN eats more then they feel anxious
        They eat less to remain calm/ produce less serotonin
        Cycle
        In addition to this, eating less can result in changes serotonin receptor ratios causing more disruption to serotonin levels
      3. Evaluation
        Weaknesses
        Hsu (1990)
        there is not yet sufficient evidence to indicate whether a change in a neurotransmitter levels are a cause of anorexia, an effect or merely a correlate
        old research
        Numerous other hormones have also been linked to eating disorders.
        Stress triggers production of cortisol
        very high levels of cortisol have been observed in patients with AN and Bulimia
        Cortisol also inhibits the release of a powerful appetite stimulant - results in decreased appetite
        Strengths
        Kaplan and Woodside (1987)
        showed that in animals , serotonin seems to induce satiation and suppress the appetite
        Bailer et al (2005)
        found that recovered anorexic patients showed increased levels of serotonin in the brain.
        this strongly related to measures of anxiety in the women
        both anxiety and increased serotonin persist even a year following recovery
        A lot of research in this area is conducted using brain scans which are objective
        Haleem (2012)
        suggested that serotonin production was associated with a restricted diet
        don't know which one causes the other (unclear cause)
        Kaye et al (1991)
        found increased levels of serotonin in normal weight anorexics but normal levels of dopamine activity
        predominantly serotonin and not dopamine
        It has been suggested that if AN is seen as having a biological cause then there will be less stigma attached and less blame
        application
2. Social
  1. Sociocultural Theory
    1. highlights the role that society plays in laying expectations on girls and women, particularly on the way they should look
    2. The theory argues that young girls, in particular, are likely to see themselves as unattractive unless they're able to have the popular 'ideal' figure
      1. Their struggle with food is an attempt to overcome feelings of low self-esteem that society sub-consciously induces, and to attain a sense of popularity
    3. as a society we have a preoccupation with losing weight
    4. certain subgroups are more likely to suffer
      1. Eg. AN more likely to occur in dance or modelling students compared to other students
        value placed on being thin
    5. eating disorder campaigners argue that the size 0 image portrays that fashion is for slim people and that 'people are actually this size'
      1. In the UK the average female is a size 14-16
        Size 0 promotes a very distorted view of body image and leads to negative comparisons
    6. Evaluation
      1. Weaknesses
        Many people live in societies that favour 'thin' but don't develop AN
        AN exists in other cultures, not just those concerned with promoting thinness
        Feminist researchers argue that eating disorders aren't a modern disease but has existed under various names for centuries
        Moreover, eating disorders affect not just young girls, but older men and women as well - however doctors and counsellors have tended to focus attention primarily on young girls and their bodies
        the description of girls as highly prone to vulnerability is a means to confine young girls to specific roles that are approved of by western, patriarchal societies where gender inequality still prevails
        Disease creation becomes a way of gender control
      2. Strengths
        Diagnosis of AN has steadily increased since the 1950s. This increase correlates with the use of slimmer models
        Willemsen & Hoek (2006)
        found that a black women who developed AN had grown up in a culture that valued voluptuousness as being attractive
        she developed AN after moving to a western culture valuing thinness
        Becker et al (2002)
        found that in Fiji before TV was introduced that girls were unlikely to be concerned with diet and slimming
        After TV was introduced they were more concerned with diet and slimming
Treatments
1. Social
  1. Family Based Therapy (the Maudsley Approach)
    1. Outpatient
    2. opposes the notion that families are pathological or should be blamed for the development of AN
    3. 15-20 treatment sessions over about 12 months
    4. 3 Phases
      1. Phase I: weight restoration
        therapist assesses family's typical interaction pattern and eating habits
        Align patient with his/her siblings
        assists parents in feeding their child
        a family meal is conducted
        Support & empathy but remaining verbally persistent
        Uncritical stance that symptoms are outside of their control
      2. Phase II: returning control over to the adolescent
        discussions
        parental concerns addressed
        weight gain with minimum tension encouraged
        Evaulation
        Weaknesses
        Ethics
        individual can feel forced into it/ lack of right to withdraw
        can make anxiety worse
        If treatment is inadequate (bad parents) then it can be dangerous
        Demands lots of time from parents
        during the first 2 weeks, the patient doesn't go to school and one parent must be available around the clock to feed their child
        Specific for adolescents and young adults
        low population validity
        Doesn't address possible biological cause or possible influences in the media
        Dimitropoulos et al (2015)
        study involved content analysis, 7 interviews and 6 focus groups involving 34 clinicians
        Found that FBT can be adapted each time it is used, found clinicians varied the treatment according to the individual, including their level of independence
        If FBT is varied then it's harder to study and draw conclusions about
        Ideographic
        Strengths
        2010 study in JAMA Psychiatry
        comparing Maudsley to adolescent-focused therapy. 120 ptts.
        found that the 2 had similar results when the treatment ended, but that Maudsley had better remission rates at 6 and 12 months later
        success rate at 50 to 70%
        Le Grange and Eisler (2009)
        in a 5 year follow up found up to 90% of those involved fully recovered
        Addresses possible problems in family dynamics and attitudes to eating
      3. Phase III: establishing healthy adolescent identity
        maintain weight above 95% of ideal weight on their own
        focus on the impact that AN has had
        central issues of adolescence
        appropriate parental boundaries
2. Biological
  1. Drugs
    1. Antipsychotics
      1. block dopamine
      2. lowers levels of anxiety and also enables weight gain (convenient side effect)
      3. Chlorpromazine
      4. Olanzapine - 5mg daily
      5. Evaluation
        Strengths
        Court et al (2010)
        found that using low-dose quetiapine (antipsychotic) showed psychological and physical improvements with few side effects, using 33 patients with AN
        Dr Hany Bissada et al
        randomised, double blind, placebo-controlled trial
        Olanzopine resulted in greater rate in increase in weight, greater decrease in obsessive symptoms
        3 patients with AN, on 5mg of Olanzapine a day - all restored body weight and appetite as well as their body self-image
        Weaknesses
        Ethics
        side effects may cause harm
        lack of right to withdraw
        Zhu & Walsh (2002) and Casper (2003)
        suggest that drugs have limited value for AN, possibly because patients do not take the medication and instead try to hide it
        success of treatment may depend on it being carried out in an appropriate setting eg. alongside FBT
    2. Antidepressants
      1. increase serotonin
      2. treat depression and anxiety that accompanies AN
      3. Serotonin re-uptake inhibitor (SRIs) works by blocking action of serotonin transporter - increased serotonin concentration
        Eg. Fluoxetine - help with maintaining weight and recovery
        Eg. Citalopram - helps with depression, obsessions and compulsions
        Eg. Venlafaxine
        weight gain when combined with CBT
      4. Evaluation
        Weaknesses
        Crisp et al (1987)
        found that clomipramine (antidepressant) didn't give any significant weight gain for 16 patients with AN, compared with a placebo
        Myung Team Experiment
        examined feeding behaviour in rats after 2 weeks of administering Fluoxetine daily
        led to a substantial reduction in food intake
        Fluoxetine has been found to reduce food intake and weight gain
        Fluoxetine side effects include: vomiting, nausea, diarrhoea, feeling of anxiousness
        Strengths
        addresses biological cause
Guardia et al (2012)
1. Imagining one's own and someone else's body actions: Dissociation in AN
  1. Aim
    1. to continue previous research by the same team that had found that patients with AN found it difficult to gauge their own body size and misjudged their ability to fit through a door frame that was clearly big enough for them
      1. The study wanted to test this phenomenon further by considering whether this perceptual problem existed beyond the individual to other people
        Do anorexics misjudge the body size of other people?
  2. Procedure
    1. 25 female ppts from a clinic for eating disorders in Lille, France, all of whom met the DSM-IV criteria for AN were used alongside 25 healthy matched female controls who were all students (opportunity sampling)
      1. A door frame was projected onto a wall to give the illusion of an opening that the ppts could possibly walk through
        51 width shapes were projected varying from 30cm wide to 80cm wide - these were presented in random order, and each one presented 4 times to each ppt
        Every ppt was asked to predict if they could walk through each door frame at normal speed without turning to the side (first person perspective)
        They were then asked whether another female researcher standing in the room could fit through the frame (third person perspective)
  3. Results
    1. the group of patients with AN showed a significant overestimation of body size in themselves, judging that they would be unable to fit through door frames that were considerably bigger than their actual body size
      1. However the same was not found in 3rd party judgments. They were much more accurate in whether the researcher could fit through
        the researchers also found a correlation between the 'passability' judgments made by the AN group and their pre-illness body weight/ size
        The control group have a much lower perceived ratio showing their image of their body weight is much smaller and that they don't have body dysmorphia
        No difference between 1st and 3rd person perceived ratios - showing the AN group have body dysmorphia that doesn't extend to other people
  4. Conclusion
    1. results suggest that body overestimation can affect judgments about the capacity for action but only when they concern the patient's own body
      1. This could be related to impairments of overall network involved in the emergence of the body schema and in one's own perspective judgments
        Overestimation of the body schema might occur because the CNS hasn't updated the new, emaciated body, with maintenance of an incorrect representation based on the patient's pre-AN dimensions - the brain doesn't perceive their current size accurately
        It was also discovered that patients who had lost weight in the 6 months prior to the study showed a greater difference between their own and the 'other person' passability perceptions.
        suggests that when anorexics lose weight their CNS can't update the body image schema quickly enough to provide an accurate representation of current body size.
        This might explain why patients with AN continue to see themselves as bigger than they are and strive to continue to lose weight because the brain doesn't perceive their current size accuratlely
  5. Evaluation
    1. Strengths
      1. Highly controlled
        replicable
        establish cause and effect
        high internal validity
      2. Shows consistency with other studies' findings
      3. Showed each shape 4 times - consistency through test and retest
      4. Application
        Can help with treatment of AN
        backs up idea of body dysmorphia
      5. lab exp
      6. standardised procedure
      7. Matched pairs - reduces individual differences
      8. Reduced order effects by showing door frames in a different order to each ppt
      9. Control group have similar results for 1st and 3rd perspective - increased validity
      10. Ethics
        debrief
        right to withdraw
        informed consent
        confidentiality
    2. Weaknesses
      1. small sample
        gender bias
        low population validity
        DSM used in France - patients may be misdiagnosed
        possible culture bias
      2. large error margins that overlap in graph
        may not show SD
        wide spread of data
      3. unrealistic setting
        low ecological validity
        possible demand characteristics
      4. Unrealistic task
        low mundane realism
        scale used may mean more mundane realism than previous studies
      5. opportunity sampling
        only get one type of person
      6. possible individual differences
      7. Ethics
        possible embarrasment
        dangerous to use AN patients

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	Created by Ella Middlemiss almost 8 years ago