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Contextualizing disorders Eating Disorders

z Culture and gender are going to affect these in very large ways – Are there different cultures with with more emphasis on physicality? z Are there subcultures within the culture? – Is one gender, ethnicity, etc. more at risk for struggling with eating issues? z Need to consider the context in which this “disordered” eating behavior occurs z Is the behavior distressing to the individual or others (or both)? 1 2

Contextualizing eating disorders Contextualizing eating disorders

z What is the bigger picture where we see these z Essential issues with contextualizing persons behaviors? with psychotic behaviors – What is going on in the person’s life? – Suicidality – May be causing other family/relationship probs – – May be facilitated by family/relationship probs safety z What is the individual trying to achieve with these – Eating patterns eating strategies? – or encouragement (for loss or gain)

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General Considerations with Psychological causes of weight loss

z Physiologic causes of weight loss z : – Cancer – appetite disturbance or change – Autoimmune diseases (lupus, AIDS) z Obsessive-compulsive disorder: – Intestinal diseases – complicated rituals around eating which may – Thyroid disease make getting adequate nutrition very difficult – Infections

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1 Psychological causes of weight loss Eating Disorders

z : z – that they are being poisoned and may z Bulimia refuse to eat. z Eating Dis NOS z : z () – symptoms of multiple disorders, including loss of appetite; may lose weight

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Anorexia Nervosa

z Diagnostic Criteria z disturbance in body weight or shape is experienced z refusal to maintain a body weight consistent with z undue influence of weight/shape on self-evaluation build, age and height z denial of seriousness of problem z 85% or less than considered typical for similar build, z if postmenarcheal female age and height – At least three consecutive menstrual cycles must be z failure to make missed, if the woman was menstruating previously before onset z individual experiences intense and overwhelming – (a woman is considered to have amenorrhea if her periods fear of gaining weight or becoming fat, even though occur only following , e.g., estrogen, administration)

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AN Specifiers: Considerations of AN

z restricting type z starve selves to thinness and death z binge-eating/purging type z over-control of eating behavior and relentless pursuit of thinness – Bulimic behavior, which occurs only when associated with a period of AN z weight is 15-20% below what would be considered "ideal" weight by many z many begin with normal , then become extreme - e.g., limit caloric intake to 600 calories/day

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2 Considerations of AN Considerations of AN

z person becomes phobic about gaining weight z often times they wear bulky clothes (big sweaters) as person is preoccupied with thinness but become they get thinner and thinner to camouflage thinness obsessed with food and food related issues – because they are cold - they've lost most of their body fat z person may become gourmet cook -- cook for others (insulator) though z they develop brittle hair and nails z these people will eat alone often times z eyes become sunken, lower body temperature, pulse z may be hyperactive, may be very into exercise as drops, develop part of method of losing weight – body will begin to feed off of itself, off its own tissue to survive

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Considerations of AN Complications of AN

z often times as this progresses, the person z 6 to 20% eventually will die from their will report difficulty thinking clearly disease z hospitalization is necessary at extreme ends – 30 to 50 percent of the deaths due to to keep person alive -- i.v. feedings – remainder are due to medical complications z medical complications…

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Cardiac (Heart problems) Gastrointestinal Problems

z Slowed heart rate z Delayed gastric emptying, leaving person z Low feeling bloated and full z Irregular heart rate z Constipation z Heart failure z Esophageal perforation z Cardiomyopathy

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3 Other problems of AN Other problems of AN

z z Skin z Kidney Damage – Development of baby-like skin over body and face z Dental – Dry, scaly skin – Erosion of dental enamel from – Cavities z Yellow tinge to skin z Blood z Green tinge to skin – – Low white count – Low platelet count

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Bulimia Nervosa

z Diagnostic Criteria z Diagnostic Criteria z recurrent episodes of , occurring on average twice z Recurrent compensatory strategies to prevent a month for a minimum of three months, which consists of: gaining any weight, including self-induced vomiting; z eating, in a discrete period of time (e.g., within any 2-hour period), an amount of food that is definitely larger than most overusing laxatives, , enemas, or other people would eat during a similar period of time and under medications; refusing to eat (fasting); or excessive similar circumstances exercise z a sense of lack of control over eating during the episode (e.g., a z Self-evaluation is unduly influenced by feeling that one cannot stop eating or control what or how much and weight one is eating) z not just due to AN

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Bulimia Nervosa Considerations of BN

z Specifiers: z person tends to be very secretive in both – Purging Type: eating and purging z The person regularly engages in self-induced vomiting or the misuse of laxatives, diuretics, or enemas z person may use diet pills in addition to – Non-purging Type: purging z The person has used other inappropriate compensatory z can be very painful to ingest massive behaviors, such as fasting or excessive exercise, but has not regularly engaged in self-induced vomiting or the misuse of amounts of calories laxatives, or enemas z look for “soft foods” as choice for purging

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4 Considerations of BN Considerations of BN

z person often feels very depressed afterwards z onset for these disorders is typically between z see this behavior in borderline p.d.s, and in incest the ages of 13-22 survivors z very negative outcomes are possible with z studies show that 61% of college women have some bulimia kind of eating disturbance - chronic , restrained eaters – death is a possibility with bulimia – about 0.1 to 1% of college women meet definition of – damage the system anorexia – damage to stomach – bulimics are more common – become more and more withdrawn z one study indicated that 1-5% of freshman women are bulimic

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Complications of BN Complications of BN

z Digestive z Kidney Damage – Enlarged salivary glands z Enlarged brain ventricles – Delayed gastric emptying, leaving person feeling z Dental bloated and full – Erosion of dental enamel from vomiting – Constipation – Cavities – Esophageal perforation – Pancreatitis

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Eating Disorders Not Otherwise Complications of BN Specified

z Blood z Individuals who have an eating disorder of clinical severity but do not meet criteria for either Anorexia or Bulimia – Anemia z Common in clinical practice – Low white count z Includes which is characterized by binge eating in the absence of compensatory behaviors – Low platelet count z repeated episodes of binge eating without the compensation of z Skin exercising, vomiting or fasting z This diagnosis is likely to have its own, individual listing in – Dry, scaly skin future editions of the DSM

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5 Rule-outs for Bulimia Rule-outs for Eating Disorders

z Anorexia Nervosa, Binge-Eating/Purging z Major Depressive Disorder with Atypical Type Features – Bulimic behavior, which occurs only when – associated with a pattern of associated with a period of anorexia – but these people do not engage in compensatory behaviors (purging).

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Rule-outs for Eating Disorders Rule-outs for Eating Disorders

z Disorders z Kline-Levin syndrome – some people vomit in response to anxiety – disturbed eating pattern that may resemble binge eating, often accompanied by – Presence or absence of being upset with body (sleeping too much) and image and/or disturbed eating patterns differentiates eating disorder from anxiety-based z Presence or absence of vomiting disturbance differentiates the person with an eating disorder from one with this neurologically based condition.

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Main Treatment Considerations for Eating Disorders: Eating Disorder treatments

z Developing successful coping strategies z Research has focused mostly on Bulimia, but z Monitoring food intake (diaries) treatment strategies are relevant to the other z Monitoring exercise (diaries) disorders. z Responding to z Wide range of therapies have been used to z Learning to eat (fullness, calories, energy levels) treat individuals with eating disorders z Learning portions including: z Accepting body image

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6 Eating Disorder treatments Eating Disorder treatments

– CBT z Two most thoroughly studied and best- – Behavior therapy documented treatments are anti-depressant – IPT medication and CBT – Psychodynamic therapy – IPT and CBT appear to be equally effective in the – long term but CBT is superior in the short term – Experiential therapy – The combination of CBT and antidepressant drug treatment appears to be no more effective that – 12-Step approach based on addiction models CBT alone. – Pharmacology

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Pharmacological treatment Pharmacological treatment

z Advantages: z Disadvantages: – Studies involving tricyclics (i.e. imipramine and – Most patients rapidly when medication is desipramine), monoamine oxidase inihibitors (i.e. withdrawn. phenelzine) and SSRIs (i.e. fluoxetine) have shown significant improvements. – High drop-out rate. – mean reduction in the rate of purging of 82% – General reluctance of individuals to accept – review (Craighead and Agras, 1991) medication as the sole form of treatment. – Does not address central issue of faulty beliefs about weight and body shape.

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Cognitive Behavioral Therapy Cognitive Behavioral Therapy

z Clinically significant reductions in binge z Improvements have also been found in eating (mean = 51% to 71%) and purging common comorbid complaints such as (mean = 36% to 56%). depression, low self-esteem, impaired social z Dietary restraint is reduced. functioning and personality disorders. z Attitudes to shape and weight improve. z It can be tailored to the individual's needs. z Maintenance of change has been shown to be reasonably good at one-year follow-up.

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7 Eating Disorders Emergencies Body Dysmorphic Disorder

z fluid imbalance (dehydration) z Preoccupation with an imagined defect in appearance. z electrolyte imbalances (potassium depletion) – If a slight physical anomaly is present, the person's concern is markedly excessive z Potassium depletion is the mechanism by – The preoccupation causes clinically significant distress or which the heart can fail, causing sudden impairment in social, occupational, or other important areas death of functioning – The preoccupation is not better accounted for by another z e.g., dissatisfaction with body shape and size in Anorexia Nervosa

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Body Dysmorphic Disorder Contextualizing Eating Disorders

z Talked about as an OCD z Always keep in mind these are on continuum and as an Eating Disorder – Many, many people engage in problematic dieting strategies z Use exposure based therapies z Consideration of family and relationship dynamics – come from family that places great emphasis on physical beauty – 70% of these women tend to be on diets as early as elementary school

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Contextualizing Eating Disorders

z Considerations of culture – Societal “pressures” z Considerations of social norms

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