Anorexia Nervosa

Ella Middlemiss
Mind Map by Ella Middlemiss, updated more than 1 year ago
Ella Middlemiss
Created by Ella Middlemiss over 4 years ago


Includes: symptoms, serotonin explanation, sociocultural explanation, family based therapy, antipsychotics, antidepressants, Guardia et al (2012)

Resource summary

Anorexia Nervosa
  1. What is it?
    1. Symptoms
      1. refusal to eat and maintain a minimum average expected body weight
        1. Fear of gaining weight or becoming fat
          1. Distorted perception of body weight and shape
            1. Amenorrhea
              1. absence of at least 3 consecutive menstrual cycles
              2. Weight less than 85% of expected
              3. Prevalence
                1. 90% of cases are in females between 13 and 18 years of age
                  1. rarely begins before puberty
                    1. sometimes younger children can suffer from it
                    2. 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
                        1. 60% follow an episodic pattern of weight gain and relapse over a number of years
                          1. 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
                        2. Explanations
                          1. Biological
                            1. Neurotransmitters
                              1. Hypothalamus regulates eating
                                1. Amino acids in food leads to serotonin production
                                  1. In someone without AN, they feel full with no anxiety
                                    1. In someone with AN, they're eating less
                                      1. the brain overcompensates for this by producing more serotonin
                                        1. therefore if the person with AN eats more then they feel anxious
                                          1. They eat less to remain calm/ produce less serotonin
                                            1. Cycle
                                              1. In addition to this, eating less can result in changes serotonin receptor ratios causing more disruption to serotonin levels
                                        2. Evaluation
                                          1. Weaknesses
                                            1. Hsu (1990)
                                              1. 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
                                                1. old research
                                              2. Numerous other hormones have also been linked to eating disorders.
                                                1. Stress triggers production of cortisol
                                                  1. very high levels of cortisol have been observed in patients with AN and Bulimia
                                                    1. Cortisol also inhibits the release of a powerful appetite stimulant - results in decreased appetite
                                                2. Strengths
                                                  1. Kaplan and Woodside (1987)
                                                    1. showed that in animals , serotonin seems to induce satiation and suppress the appetite
                                                    2. Bailer et al (2005)
                                                      1. found that recovered anorexic patients showed increased levels of serotonin in the brain.
                                                        1. this strongly related to measures of anxiety in the women
                                                          1. both anxiety and increased serotonin persist even a year following recovery
                                                        2. A lot of research in this area is conducted using brain scans which are objective
                                                          1. Haleem (2012)
                                                            1. suggested that serotonin production was associated with a restricted diet
                                                              1. don't know which one causes the other (unclear cause)
                                                            2. Kaye et al (1991)
                                                              1. found increased levels of serotonin in normal weight anorexics but normal levels of dopamine activity
                                                                1. predominantly serotonin and not dopamine
                                                              2. It has been suggested that if AN is seen as having a biological cause then there will be less stigma attached and less blame
                                                                1. 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
                                                            1. 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
                                                              2. as a society we have a preoccupation with losing weight
                                                                1. certain subgroups are more likely to suffer
                                                                  1. Eg. AN more likely to occur in dance or modelling students compared to other students
                                                                    1. value placed on being thin
                                                                  2. 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
                                                                      1. Size 0 promotes a very distorted view of body image and leads to negative comparisons
                                                                    2. Evaluation
                                                                      1. Weaknesses
                                                                        1. Many people live in societies that favour 'thin' but don't develop AN
                                                                          1. AN exists in other cultures, not just those concerned with promoting thinness
                                                                            1. Feminist researchers argue that eating disorders aren't a modern disease but has existed under various names for centuries
                                                                              1. 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
                                                                                1. 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
                                                                                  1. Disease creation becomes a way of gender control
                                                                            2. Strengths
                                                                              1. Diagnosis of AN has steadily increased since the 1950s. This increase correlates with the use of slimmer models
                                                                                1. Willemsen & Hoek (2006)
                                                                                  1. found that a black women who developed AN had grown up in a culture that valued voluptuousness as being attractive
                                                                                    1. she developed AN after moving to a western culture valuing thinness
                                                                                  2. Becker et al (2002)
                                                                                    1. found that in Fiji before TV was introduced that girls were unlikely to be concerned with diet and slimming
                                                                                      1. After TV was introduced they were more concerned with diet and slimming
                                                                          2. Treatments
                                                                            1. Social
                                                                              1. Family Based Therapy (the Maudsley Approach)
                                                                                1. Outpatient
                                                                                  1. opposes the notion that families are pathological or should be blamed for the development of AN
                                                                                    1. 15-20 treatment sessions over about 12 months
                                                                                      1. 3 Phases
                                                                                        1. Phase I: weight restoration
                                                                                          1. therapist assesses family's typical interaction pattern and eating habits
                                                                                            1. Align patient with his/her siblings
                                                                                              1. assists parents in feeding their child
                                                                                                1. a family meal is conducted
                                                                                                  1. Support & empathy but remaining verbally persistent
                                                                                                    1. Uncritical stance that symptoms are outside of their control
                                                                                                    2. Phase II: returning control over to the adolescent
                                                                                                      1. discussions
                                                                                                        1. parental concerns addressed
                                                                                                        2. weight gain with minimum tension encouraged
                                                                                                          1. Evaulation
                                                                                                            1. Weaknesses
                                                                                                              1. Ethics
                                                                                                                1. individual can feel forced into it/ lack of right to withdraw
                                                                                                                  1. can make anxiety worse
                                                                                                                2. If treatment is inadequate (bad parents) then it can be dangerous
                                                                                                                  1. Demands lots of time from parents
                                                                                                                    1. 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
                                                                                                                    2. Specific for adolescents and young adults
                                                                                                                      1. low population validity
                                                                                                                      2. Doesn't address possible biological cause or possible influences in the media
                                                                                                                        1. Dimitropoulos et al (2015)
                                                                                                                          1. study involved content analysis, 7 interviews and 6 focus groups involving 34 clinicians
                                                                                                                            1. 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
                                                                                                                              1. If FBT is varied then it's harder to study and draw conclusions about
                                                                                                                                1. Ideographic
                                                                                                                          2. Strengths
                                                                                                                            1. 2010 study in JAMA Psychiatry
                                                                                                                              1. comparing Maudsley to adolescent-focused therapy. 120 ptts.
                                                                                                                                1. found that the 2 had similar results when the treatment ended, but that Maudsley had better remission rates at 6 and 12 months later
                                                                                                                                  1. success rate at 50 to 70%
                                                                                                                              2. Le Grange and Eisler (2009)
                                                                                                                                1. in a 5 year follow up found up to 90% of those involved fully recovered
                                                                                                                                2. Addresses possible problems in family dynamics and attitudes to eating
                                                                                                                          3. Phase III: establishing healthy adolescent identity
                                                                                                                            1. maintain weight above 95% of ideal weight on their own
                                                                                                                              1. focus on the impact that AN has had
                                                                                                                                1. central issues of adolescence
                                                                                                                                  1. appropriate parental boundaries
                                                                                                                          4. Biological
                                                                                                                            1. Drugs
                                                                                                                              1. Antipsychotics
                                                                                                                                1. block dopamine
                                                                                                                                  1. lowers levels of anxiety and also enables weight gain (convenient side effect)
                                                                                                                                    1. Chlorpromazine
                                                                                                                                      1. Olanzapine - 5mg daily
                                                                                                                                        1. Evaluation
                                                                                                                                          1. Strengths
                                                                                                                                            1. Court et al (2010)
                                                                                                                                              1. found that using low-dose quetiapine (antipsychotic) showed psychological and physical improvements with few side effects, using 33 patients with AN
                                                                                                                                              2. Dr Hany Bissada et al
                                                                                                                                                1. randomised, double blind, placebo-controlled trial
                                                                                                                                                  1. Olanzopine resulted in greater rate in increase in weight, greater decrease in obsessive symptoms
                                                                                                                                                2. 3 patients with AN, on 5mg of Olanzapine a day - all restored body weight and appetite as well as their body self-image
                                                                                                                                                3. Weaknesses
                                                                                                                                                  1. Ethics
                                                                                                                                                    1. side effects may cause harm
                                                                                                                                                      1. lack of right to withdraw
                                                                                                                                                      2. Zhu & Walsh (2002) and Casper (2003)
                                                                                                                                                        1. suggest that drugs have limited value for AN, possibly because patients do not take the medication and instead try to hide it
                                                                                                                                                        2. success of treatment may depend on it being carried out in an appropriate setting eg. alongside FBT
                                                                                                                                                    2. Antidepressants
                                                                                                                                                      1. increase serotonin
                                                                                                                                                        1. treat depression and anxiety that accompanies AN
                                                                                                                                                          1. Serotonin re-uptake inhibitor (SRIs) works by blocking action of serotonin transporter - increased serotonin concentration
                                                                                                                                                            1. Eg. Fluoxetine - help with maintaining weight and recovery
                                                                                                                                                              1. Eg. Citalopram - helps with depression, obsessions and compulsions
                                                                                                                                                                1. Eg. Venlafaxine
                                                                                                                                                                  1. weight gain when combined with CBT
                                                                                                                                                                2. Evaluation
                                                                                                                                                                  1. Weaknesses
                                                                                                                                                                    1. Crisp et al (1987)
                                                                                                                                                                      1. found that clomipramine (antidepressant) didn't give any significant weight gain for 16 patients with AN, compared with a placebo
                                                                                                                                                                      2. Myung Team Experiment
                                                                                                                                                                        1. examined feeding behaviour in rats after 2 weeks of administering Fluoxetine daily
                                                                                                                                                                          1. led to a substantial reduction in food intake
                                                                                                                                                                        2. Fluoxetine has been found to reduce food intake and weight gain
                                                                                                                                                                          1. Fluoxetine side effects include: vomiting, nausea, diarrhoea, feeling of anxiousness
                                                                                                                                                                        3. Strengths
                                                                                                                                                                          1. addresses biological cause
                                                                                                                                                                3. 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
                                                                                                                                                                          1. 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
                                                                                                                                                                            1. 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
                                                                                                                                                                              1. 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)
                                                                                                                                                                                1. They were then asked whether another female researcher standing in the room could fit through the frame (third person perspective)
                                                                                                                                                                        2. 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
                                                                                                                                                                              1. the researchers also found a correlation between the 'passability' judgments made by the AN group and their pre-illness body weight/ size
                                                                                                                                                                                1. 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
                                                                                                                                                                                  1. No difference between 1st and 3rd person perceived ratios - showing the AN group have body dysmorphia that doesn't extend to other people
                                                                                                                                                                          2. 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
                                                                                                                                                                                1. 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
                                                                                                                                                                                  1. 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.
                                                                                                                                                                                    1. 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.
                                                                                                                                                                                      1. 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
                                                                                                                                                                            2. Evaluation
                                                                                                                                                                              1. Strengths
                                                                                                                                                                                1. Highly controlled
                                                                                                                                                                                  1. replicable
                                                                                                                                                                                    1. establish cause and effect
                                                                                                                                                                                      1. high internal validity
                                                                                                                                                                                    2. Shows consistency with other studies' findings
                                                                                                                                                                                      1. Showed each shape 4 times - consistency through test and retest
                                                                                                                                                                                        1. Application
                                                                                                                                                                                          1. Can help with treatment of AN
                                                                                                                                                                                            1. backs up idea of body dysmorphia
                                                                                                                                                                                            2. lab exp
                                                                                                                                                                                              1. standardised procedure
                                                                                                                                                                                                1. Matched pairs - reduces individual differences
                                                                                                                                                                                                  1. Reduced order effects by showing door frames in a different order to each ppt
                                                                                                                                                                                                    1. Control group have similar results for 1st and 3rd perspective - increased validity
                                                                                                                                                                                                      1. Ethics
                                                                                                                                                                                                        1. debrief
                                                                                                                                                                                                          1. right to withdraw
                                                                                                                                                                                                            1. informed consent
                                                                                                                                                                                                              1. confidentiality
                                                                                                                                                                                                            2. Weaknesses
                                                                                                                                                                                                              1. small sample
                                                                                                                                                                                                                1. gender bias
                                                                                                                                                                                                                  1. low population validity
                                                                                                                                                                                                                  2. DSM used in France - patients may be misdiagnosed
                                                                                                                                                                                                                    1. possible culture bias
                                                                                                                                                                                                                    2. large error margins that overlap in graph
                                                                                                                                                                                                                      1. may not show SD
                                                                                                                                                                                                                        1. wide spread of data
                                                                                                                                                                                                                      2. unrealistic setting
                                                                                                                                                                                                                        1. low ecological validity
                                                                                                                                                                                                                          1. possible demand characteristics
                                                                                                                                                                                                                          2. Unrealistic task
                                                                                                                                                                                                                            1. low mundane realism
                                                                                                                                                                                                                              1. scale used may mean more mundane realism than previous studies
                                                                                                                                                                                                                            2. opportunity sampling
                                                                                                                                                                                                                              1. only get one type of person
                                                                                                                                                                                                                              2. possible individual differences
                                                                                                                                                                                                                                1. Ethics
                                                                                                                                                                                                                                  1. possible embarrasment
                                                                                                                                                                                                                                    1. dangerous to use AN patients
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