Chapter 9

Bulimia nervosa compensatory behaviors (vomiting, laxatives, diuretics, enemas, exercise)

After a binge, they try to compensate and "undo" the caloric effects - vomiting (vomiting actually fails to prevent the absorption of half of the calories consumed during a binge) - laxatives - enemas - exercise - diuretics

Bulimia nervosa

Bulimia Nervosa is characterized by binges, which are repeated bouts of uncontrolled overeating during a limited period of time. - disorder is also characterized by inappropriate compensatory behaviors (purges) , including forced vomiting, misusing laxatives, diuretics, or enemas, fasting, or exercising excessively. DSM V Checklist for Bulimia Nervosa 1. Recurrent episodes of binge eating. 2. Recurrent inappropriate compensatory behavior in order to prevent weight gain. 3. Symptoms continuing, on average, at least once a week for three months. 4. Undue influence of weight or shape on self - evaluation. Who receives it: - 90% - 95% occurs in females - peak age of onset is 15 - 21 years - symptoms may last for several years with periodic letup - weight of people with bulimia usually stays within a normal range, although it may fluctuate marked within the range. Can be overweight, underweight or normal and persists once a week for three months. Some may be qualified for diagnosis of anorexia.

Treatment for Binge Eating Disorder (cognitive-behavioral therapy, antidepressants)

Cognitive - Behavior Therapy, other forms of psychotherapy, and, in some cases, antidepressant medications are provided to reduce or eliminate binge patterns and to change disturbed thinking. - People with binge eating disorder who are overweight require additional intervention - disorder was found to be present in 1/3 of individuals 12 years after hospitalization and 36% of individuals were still significantly overweight.

Anorexia and Bulimia Differences

Differences: - people with bulimia are more concerned about pleasing others, being attractive to others, and having intimate relationships - people with bulimia tend to be more sexually experienced and active - people with bulimia are more likely to have histories of mood swings, low frustration tolerance, and poor coping. -more than 1/3 of people with bulimia display characteristics of a personality disorder, particularly borderline personality disorder. - 1/2 women with bulimia nervosa experience amenorrhea vs almost all women with anorexia nervosa - people with bulmia nervosa suffer damage caused by purging, especially from vomiting and laxatives.

Treatment for Anorexia nervosa (weight restoration, cognitive behavioral therapy, changing family interactions

Immediate aim: - regain lost weight - recover from malnourishment - eat normally again Two goals: 1. Correct the dangerous eating pattern as quickly as possible. 2. Address the broader psychological and situational factors that have led to and maintain the eating problem. In life threatening situations, clinicians may need to force tube and intravenous feedings on patients who refuse to eat. The must overcome psychological problems to achieve improvement. Behavioral and Cognitive Treatment - Behavioral - required to monitor feelings, hunger levels, and food intakes and ties amongst those variables. - Cognitive - therapists correct disturbed cognition and education about body distortions. (recognize their need for independence and teach them more appropriate ways to be in control and identify better and trust internal sensations and feelings and change in attitude) Family Therapy - issues with separation and boundaries - family therapists may try to help the person with AND separate her feelings and needs from those of her members of her family. Positives of treatments: - weight gain is often quickly restored - menstruation often returns with return to normal weight - the death rate from anorexia nervosa is declining - 90% of patients continue to show improvement after years. Negatives of treatments: - as many as 25% patients remain troubled for years - even when it occurs, recovery is not always permanent - lingering emotional problems are common -recurs in at least 1/3 of recovered patients, usually triggered by new stresses. About 1/2 continue to experience emotional problems - particularly depression, obsessiveness, and social anxiety.

Treatment for Bulimia nervosa (cognitive behavioral therapy, antidepressants, other forms of therapy)

Immediate aims of treatment for bulimia nervosa are to: - Eliminate binge- purge patterns - Establish good eating habits - Eliminate the underlying cause of bulimic patterns Program emphasize education as much as therapy. Cognitive Behavioral Therapy: - Behavioral techniques - diaries are often a useful component of treatment and Exposure and Response prevention (ERP) is used to break the binge - purging cycle) - Therapists require clients to eat particular kinds and mounts and then preventing them from vomiting to show eating can be harmless and even constructive activity that needs no undoing. - Cognitive techniques - help clients recognize and change their maladaptive attitudes toward food, eating, weight, and shape. Typically teach individuals to identify and challenge the negative thoughts that precede the urge to binge. - guide clients to recognize, question, and eventually change their perfectionistic standards, sense of helplessness, and low self concepts. - has helped as many as 65% of patients stop binging and purging. Antipressants - during past 15 years, all groups of antidepressant drugs have been used in bulimia treatment and helped 40% of patients. - Medications are best when used in combination with other forms of therapy. - left untreated, bulimia nervosa can last for years - treatment provides immediate, significant improvement in about 40% of cases (an additional 40% show moderate response) - follow up studies suggest 10 years after treament about 75% of patients have fully or partially recovered - moderate response = decrease in binge eating and purging. Relapse can be a problem to those even that have responded successfully. Relapse can be a significant problem, even among those who respond successfully to treatment (relapses are usually triggered by stress) - Relapse is more likely among persons who had longer histories of bulimia nervosa before treatment, had vomited more fruently during the disorder, continued to vomit at the end of treatment, had histories of substance abuse, and continue to be lonely or to distrust other after treatment.

Binge Eating Disorder

Individuals with binge eating disorder engage in repeated eating binges during which they feel no control, 2/3 of people with this disorder become overweight or obese. DSM V Checklist for Binge Eating Disorder 1. Recurrent episodes of binge eating 2. Binge eating episodes are associated with 3 or more of the following symptoms: unusually rapid eating, eating large amounts without physical hunger, eating until uncomfortably full, eating alone because of embarrassment, feelings of self disgust, depression, or severe guilt after episodes. 3. Significant distress regarding binge eating. 4. Binge eating occurs, on average, at least once a week for 3 months, 5. No pattern of inappropriate compensatory behavior. Who receives it: - between 2 and 7% of population display binge eating disorder - binges and many other symptoms that characterize this pattern are similar to those seen in bulimia - those with binge eating disorder are not driven to thinness, this disorder doesn't start following a diet, and there are not large gender differences in prevalence of this disorder. - evenly distributed among males and females and people of different races - evaluate themselves largely on their weight and shape; misperceive their body size and experience extreme body dissatisfaction; struggle with feelings of depression, anxiety and perfectionism.

Bulimia Nervosa: Binges

People with bulimia have between 1 and 30 binge episodes per week - carried out in secret - may consume as many as 10,000 calories per binge episode - people eats massive amounts of food very rapidly, with minimal chewing - usually sweet, high calorie foods with soft texture, such as ice cream, cookies, doughnuts, and sandwiches. The food is hardly tasted or thought about. - preceded by feelings of great tension - binge itself may be pleasurable, it is usually followed by feelings of extreme self- blame, guilt, depression, and fears of weight gain and being discovered. - the person feels irritable, unreal and powerless to control an overwhelming need to eat "forbidden" food. During the binge, the person feels unable to stop eating. Although the binge itself may be experienced as pleasurable in sense that it relieves the unbearable tension.

Anorexia Nervosa (The Clinical Picture)

Preoccupied with food which includes thinking and reading about food and planning for meals (they dream about food and eating) and may think so much about food because they deprive themselves of it. - this relationship is not necessarily causal - becoming thin is the key goal but fear provides their motivation - people are afraid of becoming obese They think in distorted ways: - low opinion about their body shape - tend to overestimate their actual proportions - consider themselves unattractive and emphasis on perfection. - hold maladaptive attitudes and misconceptions such as " i must be perfect in every way", "I will be a better person if I deprive myself", "I can avoid guilt by not eating" Display certain psychological problems: - Depression - Anxiety - Low self - esteem - Insomnia or other sleep disturbances - substance abuse - Obsessive compulsive patterns - perfectionism in some research, people with Anorexia nervosa and others with OCD score equally high for obessiveness and compulsiveness.

Anorexia and Bulimia Similiarities

Similarities: - begin after a period of dieting - fear of becoming obese - drive to become thin - preoccupation with food, weight, appearance - feelings of anxiety, depression, obsessiveness, perfectionism - heighted risk of suicide attempts - substance abuse - distorted body perception - disturbed attitudes towards eating.

Anorexia nervosa

The main symptoms of anorexia nervosa are: - Restriction of energy intake leading to significantly low body weight. - intense fears of becoming overweight. - distorted view of weight and shape. DSM V Checklist for Anorexia Nervosa 1. Restricted net intake of nourishment, leading to significantly low body weight. 2. Intense fear of gaining weight, even though significantly underweight. 3. Disturbed body perception, undue influence of weight or shape. Who receives it: - about 90% - 95% of cases occur in females - peak age of onset is 14 t 18 years - approximately 0.5% of females develop the disorder - approximately 10:1 female to male ratio - rates of anorexia nervosa are increasing in North America, Europe and Japan - Typically, the disorder begins after a person who is slightly overweight or normal weight has been on a diet. - the escalation towards anorexia nervosa may follow a stressful event such as separation of parents, a move away from home, or an experience of personal failure - 2% - 6% become so seriously ill that they die, usually from medical problems brought about by starvation or from suicide.

Types of Anorexia Nervosa

Two main subtypes: Restricting Type Anorexia Nervosa - reduce their weight by restricting their intake of food. Eventually people with this kind of anorexia nervosa show almost no variability in diet. Restricting - weight loss is accomplished by extreme dieting, fasting, and or excessive exercise. Binge - Eating/ Purging Type Anorexia Nervosa - losing weight by forcing themselves to vomit after meals or by abusing laxatives or diuretics, and they may even engage in eating binges. may also use enamels.

Anorexia Nervosa (The Medical Picture)

caused by starvation: - Amenorrhea (absence of menstraul cycles) - low body temperature - low blood pressure - body swelling - reduced bone density (osteopenia and osteoporosis) - slow heart rate (bradycardia) - metabolic and electrolyte imbalances (can lead to death by heart failure) - dry skin, brittle nails (skin rough and cracked, nails become brittle and hands and feet to be cold and blue) - poor circulation - Lanugo (fine, silky hair that covers some newborns) on their trunk, extremities and face