Chapter 7

Nutritional Counseling (Nutritional rehabilitation)

-Dieticians & nutritionists specializing in the treatment of eating disorders -Nutritional needs for someone with anorexia nervosa -set weight goals -develop strategies for re-normalization of eating -calc caloric requirements for weight gain -Nutritional needs upon evaluation of someone with bulimia nervosa and binge eating disorder -help the patients relearn appropriate portion sizes, eat meals in a normal way, and develop strategies for decreasing urges to binge -Best utilized in conjunction with other treatments

Cognitive-behavioral therapy

-Focuses on changing one's perception about body shape, weight, eating, and sense of control -Addresses both: automatic thoughts: relatively easily accessible thoughts, evaluative in nature and core beliefs: deep,guiding principles or self-truths of the individual -Replaces negative thoughts and problematic behaviors -Use of self-monitoring is the cornerstone (via text messaging). Easily see patterns of unhealthy behavior, -master language and negative thoughts

Comorbidity and BN

80% of people with BN have another psychiatric disorder Most common disorders seen in conjunction with BN: anxiety, depression, substance use & personality disorders Examples: Elton John and Princess Diana

Comorbidity and AN

80% will suffer from major depression Up to 75% will suffer from anxiety disorders, esp OCD Anxiety as a risk factor in the development of AN

Binge Eating Disorder (BED)

A disorder characterized by regular binge eating behaviors, but without the compensatory behaviors that are part of bulimia nervosa recently put in to DSM-5 *Still under investigation* Common in people who are overweight and obese (found that 5 to 8% of the general population meet criteria) comorbidity: mood disorders, anxiety, substance use disorders

Anorexia Nervosa Facts

Affects 1% of the general population (1 out of 100) Females are 3x more likely to develop the disorder Begins in adolescence (usually after puberty) Highest mortality rate of any psychiatric disorder (10.5x more likely)

Bulimia Nervosa (BN)

An invisible disorder with normal body weight (or clearly overweight); characterized by recurrent episodes of binge eating & some form of compensatory behavior aimed at undoing the effects of the binge or preventing weight gain People with BN are perfectionist and have low self esteem but also tend to be more impulsive and have higher novelty-seeking behavior than people with AN Subtypes: -purging -non-purging

Biological factors

Biological factors to consider in the development of eating disorders: Role of the hypothalamus -influential in appetite and weight control Activity-based anorexia -animal model that focuses on excessive hyperactivity seen in patients with AN, which persists even in underweight condition. (rat unlimited access to a running wheel) Neurological -Neuroendocrine and neurohormonal system factors. Focused on the role of serotonin and dopamine and how the influence start eating and fullness Brain structure and brain functioning -reduced brain mass, brain ventricles increase in size, and loss of grey matter. -globally deceased brain glucose and increased serotonin activity in certain regions Family "genetics" -family and twin studies but no adoption studies -eating disorders run in families but not the same ones necessarily (Heritability estimates: 28-83%) -studies have identified areas on specific chromosomes for both AN and BN Although our genes establish our baseline risk, our environment can be protective (buffering) and/or triggering (risk enhancing)

Medication

Biological treatment -Commonly prescribed for AN -Need for medication specific to symptoms of Anorexia Nervosa -Fluoxetine (Prozac) is an antidepressant & SSRI used to treat Bulimia Nervosa. the only approve medication for eating disorders -No medications have been FDA approved for Binge Eating Disorder

Dialectical Behavioral Therapy (DBT)

Focus on emotional dysregulation as core problem of eating disorders Views symptoms as attempts to manage negative emotions Demonstrated effectiveness for BN, being investigated for AN

Impact of Gender and Ethnicity

Gender: More common in females than males -However consider male athletes Stereotypes: Lack of clear data Need for research with more diverse populations Factors to consider (i.e., SES, education level, familial influence) BED tends always be equal

necessary symptoms of BED

Recurrent episodes of binge eating Report of distress over binge eating Associated with three or more of the following: -eating rapidly -eating past the point of "feeling full" -eating large amounts of food when not physically hungry -eating alone due to embarrassment -feeling disgusted with oneself, depressed, or guilty

necessary symptoms of BN

Recurrent episodes of binge eating -Subjective:eating a typical or even small amount of food -Objective: eating a comparatively large amount of food Experience a lack of control over eating Engage in recurrent compensatory behaviors: -self-induced vomiting (causes dental enamel damage) -misuse of laxatives, diuretics, enemas, or other medications -fasting or excessive exercise

BMI

Scientific way for psychologists and other mental health professionals to measure just how "thin" a person really is.

Who's Considered at Risk?

Segments of the population where emphasis is placed on body shape & weight Personality traits -Perfectionism -Obsessionality -Neuroticism -Low self-esteem -Developmental tasks (leaving home for college) -Worriers

Epidemiology of bulimia nervosa

Individuals bron after 1960 are more at risk, meaning its more of a modern disease more common in females starts in mid-late adolescent or early adulthood (later than anorexia) assoc. with physical complications: fatigue. lethargy, bloating, and gastrointestinal; frequent vomiing leads to erosion of dental enamel, glands swelling; laxitive misue leads to edema, dehydration, and metabolic problems

Treatment after hospitalization

Inpatient treatment for AN -Multidisciplinary team approach -Maintenance of healthy weight -Consideration of other factors (i.e., social supports, other medical conditions, work, school, suicidal ideation, etc.) -Psychotherapy (i.e., individual, group, and family) -Privileges given as result of compliance with treatment -Treatment (comprehensive plan, including "food")

Feeding and Eating disorders of childhood

Pica: persistent eating of non-food substances (keys, rocks, magnets) Cultural pica also exists. Rumination disorder: recently eaten food is regurgitated into mouth, rechewed, reswallowed or spit out Avoidant-restrictive food intake disorder: children who exhibit restricted or otherwise inadequate eating "picky eating"

Developmental issues to consider

Weight problems Prevalence rates in childhood vs. adolescence • anorrexia nervosa in childhood is uncommon and bulima nervosa before puberty is rarely reported • earlier onset of menstraution may increase risk for bn hypothalamus is central to weight and appetite regulation Social -Leads to social isolation from peers and family Emotional -Associated with symptoms of depression and anxiety Physical -Onset of menstruation, percentage of body fat, and more mature "womanly" figures

Causes of BN

Westernized societal emphasis on the "thin ideals," culture-bound syndrome Environmental exposure Social learning Information sharing -i.e., hearing about it from friends or reading material on the disorder Personality -i.e., low self-esteem, perfectionism, more impulsive, and have higher rates of novelty seeking behaviors

Amenorrhea

absence of menstruation for at least 3 months. Eating disorders shut down reproductive system WAS apart of DSM-5 requirement

Epidemiology and course of AN

less common in boys and men has been an increase risk for 15-19 yo group tendency to be in certain groups sports and entertainment industry After recovery people tend to still have low BMI, osteoporosis, difficulties with fertility and child birth.

Interpersonal Psychotherapy (IPT)

-A brief, time-limited therapy approach that focuses on decreasing eating disorder symptoms by enhancing social skills in relationships -intervens at the symtopms and social function by Addressing 4 problem areas: 1.interpersonal disputes, 2.role transitions, 3.abnormal grief & 4.interpersonal deficits -IPT is more effective for BN but CBT is better and more rapid

Family-based interventions

-Modern approaches to family therapy - critical in treatment for AN -The Maudsley Method- empowers parents to take active role in treatment -Effective with adolescents with eating disorders

Learning Objectives

1. Anorexia nervosa is highly visible disorder due to the extreme low weight, intense fear of "feeling fat," and an overwhelming emphasis on one's shape and weight equate to self-worth. 2. Individuals with bulimia nervosa tend to be normal weight or overweight, but engage in purging behaviors such as self-induced vomiting or abuse of laxatives. 3. Binge eating disorder is usually seen in overweight or obese individuals who engage in binge eating, but do not purge. 4. Females are nine times more likely to suffer from AN and BN, versus BED tends to be equally distributed among sexes. 5. AN tends to development in early adolescence and BN occurs a little later in adolescence or early adulthood, whereas less is known about the developmental course of BED. 6. Many theories exist around the etiology of eating disorders such as psychodynamic, biological/genetic, and sociocultural. Additionally, both environmental (nature) and genetic (nurture) factors should be considered. 7. Depression and anxiety are commonly comorbid (co-occurring) with both anorexia and bulimia. 8. Some personality traits are more common in individuals with anorexia and bulimia such as perfectionism, but people with bulimia are more likely to be more impulsive. 9. Treatment for AN is centered around renutrition and weight gain, which includes the use of family therapy and CBT after weight stabilization. 10.Treatment for BN includes both medication, Prozac, and the use of CBT.

Anorexia Nervosa (AN)

A visible and serious condition marked by low body weight and fear of weight gain -Measured by body mass index (BMI) Types: Restricting: dieting, fasting or exercise Binge eating/purging: binge on food, followed by purge (vomiting, laxatives, diuretics, enemas)

Basic Treatment Goals

Anorexia nervosa -Normalization of eating behavior and weight -Increase caloric intake and weight gain -renutrition is a critical first step in AN Bulimia nervosa -Normalization of eating -Elimination of binge eating and purging Binge eating disorder -Normalization of eating -Elimination of binge eating -Weight stabilization or weight loss -Improve psychological factors (i.e., depression, self-esteem, and self-efficacy)

Other specified feeding and eating disorder (OSFED)

For those that don't meet the specific criteria of other eating disorders Five categories: -Atypical anorexia nervosa (All symtoms of AN but has normal weight) -BN of low frequency or limited duration (less than one week or less than 3 months) -BED of low frequency or limited duration (less than one week or less than 3 months) -Purging disorder (purge but not binging) -Night eating syndrome (eating when waking up at night)

Anorexia Nervosa according to DMS-5

Intense fear of gaining weight or "feeling fat" Use weight and shape as a measure of self-evaluation Perception of body size and weight is distorted Restricting or binge eating/purging subtypes Denial of illness

Psychological factors

Psychological factors to consider in the development of eating disorders: Psychodynamic: -focuses on influence of early experience. Anorexia nervosa as an escape from adult sexuality Family models of eating disorder (Salvador Minuchin): -patterns of family dysfunction among patients who sought treatment -Minuchin identified enmeshment, rigidity, over protectiveness, and poor conflict resolution in people with anorexia; later models acknowledge there is no typical family from which anorexia arises -Enmeshment: the overinvolvment of all family members in the affairs of any one member -Minuchin also championed the concept of "psychosomatic family" and worked with families around the dinner table Cognitive behavioral theories -Distorted cognition's/ thoughts related to body shape, weight, eating and personal control that lead to and maintain unhealthy eating an weight-related behaviors. Emphasize the power of thoughts to influence feelings and behaviors Sociocultural theories -focus on the ubiquitous pressure on girls and woman to be thin and the internalization of the thin ideal - emphasize Western "thin ideals" -Culture value on beauty