Eating Disorders: Identification, Treatment, Healing, & Recovery

Anorexia Nervosa - Safety

*Anorexia Nervosa has the HIGHEST mortality rate of any other psychiatric illness! (slowly killing themselves or actually committing suicide) *Upwards of 7% of mortality rate via suicide or cardiopulmonary arrest

Let's Play Barbies - NOT

Sexualization of children, especially girls, and cultural norms regarding the ideal body type - starts when we are young! *Barbie Doll Body is one aspect that has caused sexualization to start young Barbie is •7 feet tall •38 inch chest •21 inch waist •36 inch hips •Completely unattainable for any normal woman, and yet??

Genetic Influences of AN

***** **There may be a potential genetic link found in anorexia nervosa. Difficult to fully assess though, as family/environmental factors play such a predominant role in the development of this disorder: *if they are around women who value thiness then this will affect the way they think •Anorexia nervosa is more common among sisters and mothers of those with the disorder than it is among the general population. •Possible chromosomal linkage sites have been suggested. Research about the brain and eating show that certain chemicals in the brain control hunger, appetite and digestion may be imbalanced

Re-feeding Process

**When an emaciated patient first enters into an inpatient treatment, it is critical that we monitor them closely during the referring process. *Re-feeding process must be done carefully and under medical supervision - significant clinical complications may occur as the restful of fluid and electrolyte shifts during nutritional rehabilitation of malnourished patients *must not feed them too fast (slow re-introduction with food, we don't want to shock the body) Patients should be fed according to a very strict protocol including limited intake of sodium and fluids. It should be raised by 300-400 calories q 3-4 days with the weight goal of 1Kg/week Frequent monitoring of VS High collaboration with dietary services Slow process Usually done in an inpatient ED setting **Priorities Upon initial arrival at an Eating Disorder clinic: -priority is given to restoring electrolyte balance and careful referring of the patient. -NEVER force feed the patient or go into intense therapy right off the bat.

Anorexia Nervosa

*Anorexia Nervosa is an eating disorder characterized by severe food restriction, inappropriate eating habits/rituals, obsession with having a thin figure, and an irrational fear of weight gain as well as a distorted body self-perception. It is diagnosed approximately nine times more often in females than in males. The prevalence rate of anorexia nervosa among young women in the United States is approximately 1 percent. *Anorexia nervosa occurs predominantly in girls and women ages 12 to 30 years.

Binge Eating Disorder (BED)

*Definition: Binge eating disorder is an eating disorder characterized by recurrent episodes of eating large quantities of food (often very quickly and to the point of discomfort); a feeling of a loss of control during the binge; experiencing shame, distress or guilt afterwards; and NOT using unhealthy compensatory measures (e.g., purging - laxatives, exercising, vomiting ) to counter the binge eating. *It is the MOST common eating disorder in the United States - 30 to 40 percent of individuals seeking treatment for weight-loss can be diagnosed with binge eating disorder.

Motivational Interviewing (MI) & Behavioral Modification

*For the program to be successful, the client must perceive that he or she is in control of the treatment. **Behavior Modification The client has control over: •Eating •Amount of exercise pursued •Whether to induce vomiting **Staff and client agree about: •Goals •System of rewards (gets reward for good behavior) *Behavioral Modification programs usually start with a contract for weight gain, limitations of exercise, and an agreement on acceptable coping skills and participation levels.

The most effective tool

*LOVE YOURSELF

Anorexia Nervosa - Mental Health Consequences

*Mindset becomes distorted - Distorted and obsessive thoughts regarding food, exercise, and body images *Takes over one's life - loss of life in other care such as social, financial, spiritual, professional, and academic: •Anything that pulls you out of balance can destroy life and make things worse •*Complete withdrawal from family, friends, and social engagements because they don't want to be seen (holidays are especially hard because people celebrate with food)

those with AN

*Most come voluntarily for treatment

Anorexia Clinical Course

*Onset: early adolescence Can occur slowly with serious dieting resulting in emaciated body Chronic condition with relapses *Difficult to report conclusive outcomes or tell if cured after treatment because... ▪*Considered recovered if restored normal weight, menses, and eating behaviors ▪*May still have psychological factors or develop bulimia nervosa or have co-morbid psychiatric conditions *it's important to remember that anorexia is not done for attention, they actually want to hid

Family Dynamics & AN

*Some theories link family dynamics as a root cause of an adolescent to develop anorexia nervosa *how family talks about beauty and self or if the family expects perfection or are appearance orientated can lead to AN •Eating disorders often run in families, as it is learned coping skills and attitudes of weight and beauty run in families •A home environment that is overprotective and demands perfection may be an influence in the development of anorexia nervosa. These families are characterized by enmeshment, members striving for perfection, and the parents endeavor to maintain "appearances" at all costs. •Mothers who are overly concerned about their own appearances and their daughter's weight and physical attractiveness, might cause increase risk for development of eating disorders. Girls with eating disorders often have brothers and a father who are overly critical of their weight. •The issue of control may become the overriding factor. A high value is placed on perfectionism and the child feels compelled to meet these standards. Parental criticism promotes an increase in the child's obsessive & perfectionistic behavior of a child who continues to seek love, approval, and recognition •*As a teen, ED behavior can occur as a way to gain control.

ED

*eating disorder

Purging

*engaging in behaviors such as vomiting or misusing laxatives (or using diuretics or emetics) to rid the body of food

binge-purge cycle

*they diet then have cravings then binge eat then they feel guilty/shameful so they purge and continue to feel bad/digust so they diet gain.

treatments

-*family therapy for AN -*CBT for biliuma nervosa (Identifying feelings associated with the desire to binge indicates the client is making progress.) -*Psychotherapy: Support groups, CBT, and group work for BED

Two Types of AN

1. *Restricting: Someone restricts their diet to the point of starvation and have an intense fear of gaining weight. They have an abnormal pre-occupation with food, caloric intake, and food issues. -*Often accompanies strict dietary rules, over-exercising, and extreme fasting 2. *Anorexia Binge Eating: Combination of Anorexia and Bulimia; A person will restrict their diet for a long period of time and then when resuming their intake, will eat huge amounts of food. Once the binge is over, there is an overwhelming fear of gaining weight and sufferers will rid themselves of the food though purging - vomiting, over-exercise, and laxatives.

Eating Disorders (ED)

3 COMMON EATING DISORDERS* -Anorexia nervosa -Bulimia nervosa -Binge eating disorder (BED) ❖Additional: -Other Specified Feeding and Eating Disorders (OSFED) -Unspecified Feeding and Eating Disorders (UFED) *those with eating disorders do not do well in inpatient psych settings *relapse is common and the road to recovery is long

Behavioral & Emotional Sx of Binge Eating

Behavioral symptoms: •*Eating more than required (overeating) •Eating even after full •Eating continuously throughout the day with no particular time •*Most individuals with Binge Eating Disorder are in a pattern of repetitive dieting or having food rituals Emotional symptoms: • Overeating when stressed • Overeating when left alone & intense feelings of guilt and shame after binge episodes

Body Dysmorphism in AN

Body Dysmoprhism: *Patient sees body as severely distorted from reality - their eyes deceive them, they don't realize that they are too skinny Becoming obsessively concerned about imagined or minor physical defects in their appearance. *This is one of the main reasons why pts with AN deny they are ill! *Drive for thinness -Intense physical and emotional process that overrides all physiologic body cues -*Exhibit bizarre behavior centered on food -*Guilt and anger regarding food/relaxation

Additional Treatment Measures for EDs.

Cognitive Behavioral Therapy CBT is the front-line therapy option for Bulimia Nervosa CBT strives to eliminate the emotional components associated with unhealthy eating patterns by confronting irrational thinking patterns and associated feelings. Explores the emotional issues and feelings that contribute to binging and purging behaviors.

Co-morbidities associated with AN

Co-mobordities Anxiety Disorders Substance Use Disorders *OCD - usually revolving around food/food rituals Trauma/PTSD *Body Dysmorphic Disorder -

Motivational Interviewing (MI) & Behavioral Modification

Most patients with ED recognize that it has been a successful escape and means of control, even enabling them to endure life, and yet, also grapple with the dystonic and distressing experiences/thoughts/behaviors that come with AN. Behavioral conceptualizations of anorexia nervosa and bulimia emphasize the notion that the symptoms of these disorders are acquired through processes of conditioning or learning. Behavioral therapy interventions have largely focused on reduction of the phobic-like anxiety associated with eating and weight gain, along with "reinforcement" of behaviors incompatible with pathological dieting. *Eating disorders are about control and a desperate attempt to not feel out of control. -Successful eating disorder programs that focus on behavioral modification are the treatment of choice for clients diagnosed with eating disorders, because these programs allow clients to maintain control. **In that ambivalence, MI can be used as a tool to get people to focus on Behavior modification techniques to restore healthy body weight. Behavior modification therapy is used because it provides the client with control over behavioral choices. Includes rewards

Outward Signs of Bulimia

Often, signs of bulimia are difficult to asses from the outside. However, they may manifest certain physical sx that hint at Bulimia: •Frequent changes in weight •Signs of damage d/t vomiting - swelling around the jaw/cheeks, calluses on knuckles, damaged teeth; -*Russel's Sign- bruises and and calluses in the thumb or hand, this can be caused by trauma or from self induced vomiting. •*Feeling bloated/constipated (using laxatives can do this) •Fainting or dizziness •*Erosion of tooth enamel - due to acids in vomit during purging, there can be the erosion of tooth enamel(dentist first to notice eating disorders because of acid destroys teeth) •The person is usually moody and depressed

Binge Eating Disorder - Medical Complications

The health risks of BED are most commonly those associated with clinical obesity, weight stigma, and weight cycling (aka, yo-yo dieting). *risk of obesity Most people who are labeled clinically obese do not have binge eating disorder. However, of individuals with BED, up to two-thirds are labelled clinically obese; people who struggle with binge eating disorder tend to be of normal or higher-than-average weight, though BED can be diagnosed at any weight.

Additional Treatment Measures for EDs.

Treatment Reminders ·*Ensure the program implemented doesn't "control" patients (this doesn't work) ·Successes have been observed when the pt with anorexia nervosa is allowed to contract for privileges based on weight gain ·*The pt has input into the care plan and can clearly see what the treatment choices are ·*The pt has control over eating, amount of exercise, and even over whether to induce vomiting ·Goals of therapy and system of rewards and privileges are agreed upon by pt and staff ·Gives pt great deal of autonomy ·These techniques are only for weight restoration ·Pt must also be in family &/or individual therapy as well ·*Cognitive therapy helps the pt to confront irrational thinking and strive to modify distorted and maladaptive cognitions about body image & eating behaviors.

ANOREXIA BINGE EATING vs Bulimia

•*ABE is different than bulimia, because in anorexia nervosa, weight is much lower than normal body weight, while in bulimia nervosa, weight is maintained in the normal range. *ABE is a mix of bulimia and Anoxeria, they fast then eat a lot of food, and then fear that what they ate will cause them to gain weight so they vomit and use laxatives

AN - Medical Complications

•*Amenorrhea (loss of so much weight that they loss their period •*Infertility and Hormonal changes •*Arrested growth and development - hormonal development stops abruptly (body stops growing/puberty stops, hair doesn't grow) •**Cardiac issues: decreased cardiac mass, mitral valve prolapse, pericardial effusion, extreme hypotension, heart rate variability, leading cause of death •Extreme fatigue •*Significant osteoporosis •Cold Intolerance •Palpitations •Dizziness •Abdominal bloating and pain •Irritability •*Lanugo - peach fuzz on skin (severe malnutrition); excessive loss of hair and thinning of hair

Medical Complications of Bulimia

•*Bulimia is not as life-threatening as anorexia nervosa, but patients can still suffer from significant medical complications as the result of purging sx •*Significant dehydration & electrolyte imbalances (hypokalemia is common) •*GI dys-regulation - patient's body becomes dependent on laxatives for bowel movements; constipation/bloating in the abdomen •Low K levels lead to cardiac arrhytmias and kidney failures •*Poor dentation & dental deteriation r/t acid eroding enamel during vomiting; leads to a number of systemic consequences, including cardiac issues

Bulimia Nervosa

•*Bulimia: An emotional disorder involving the distortion f the body image and an obsessive desire to lose weight, in which bouts of extreme overeating are followed by depression and self-induced vomiting, purging, or fasting. *obsession to lose weight so they self-induse by vomiting after binging *Generally not life-threatening **Treatment: outpatient therapy •*those with buliuma have Better outcomes and Lower mortality rates Clinical Course •Few outward signs •Binging and purging in secret •*Typically normal weight •*Shame, guilt, disgust about binging and eating •*Also impulsivity in other aspects of life - acting-out behaviors (or other disorders ) are commonly associated with BN

Sociocultural Norms

•*Cultural pressures that glorify thinness and place values on obtaining the "perfect body" *media, tv, magazines promote weight loss, and guess who are reading or watching -little girls •Narrow definitions of beauty that include women and men of specific body weights and shapes •Cultural norms that beau people based on phsyciual appearance and not on inner qualities/strengths •Sexism and discrimination

Behavioral Sx of BN

•*Eating in secret (not in front of people) •Repetitive of obsessive behavior regarding weight •Excessive exercising •*Frequent trips to the bathroom during or shortly after meals, e/o vomiting and/or laxatives

Risk Factors for BN

•*Genetics - having a close relative who has or had bulimia, you are four times more likely to develop this disorder as well •*Sensation Seeking - may cause some individual to gorge for the pleasure of eating. They have a compulsion similar to an addiction •*Bulimia can also be triggered by environmental stress, such as family dysfunction and/or traumatic stressful life event. They succumb to the pleasure of eating, but this temporary pleasure is followed by guilt and shame. -*To reduce guilt, the bulimic purges and disposes of any evidence of the binge.

Treatment Measures for BN

•*Inpatient hospitalization only due to medical complications and/or SI •Stabilization and then normalization of eating •Restructuring of dysfunctional thoughts or attitudes •*CBT - Restructuring of dysfunctional feeling & thoughts towards eating •Medication therapy: Antidepressants •Nutrition counseling •Group psychotherapy •Support groups

Therapeutic Interventions

•*Key Note - Important to recognize that many individuals with Anorexia Nervosa strongly deny they are ill - "I don't understand why you are concerned; I am fat and need to lose this weight" •They do everything in their power to cover up their thinness and not put the spotlight onto themselves. In addition, due to body dysmorphia, they do not recognize how they really are and minimize the health risks concerned. *It is important to recognize that they must come to recovery on their own free will. •Antidepressant therapy to help address mood sx associated with ED **Family Therapy - Family Therapy is the first line of therapy for anorexia nervosa -*Involves educating the family about the disorder -Assesses the family's impact on maintaining the disorder -Assists in methods to promote adaptive functioning by the client •Supportive therapy to develop recovery goals outside of body weight

Psychological Factors of AN

•*Low self-esteem •Intense feelings of being a failure •*Perfectionism - pressures from family and/or self •*Feelings of being out of control: Control is a key feature of this disorder; restrictive eating can help gain control •*Response to change (puberty): Especially prominent in trauma Hxs •*Athletic pursuits: Especially body-image centered sports like gymnastics & dancing; ballet dancers & gymnasts are seven times more likely to develop ED than other athletes. Especially when at an elite level of competition or in a sport where lean body is prized (running, gymnastics), or where specific wt is required (wrestling & jockeys)

AN: Interpersonal Factors

•*Troubled family & personal relationships (family may need treatment too) •Difficulty expressing emotions and feelings in a family •Hx of being teased or ridiculed based on size or weight •Hx of sexual and/or physical abuse

BED s/sx

•Evidence of binge eating, including disappearance of large amounts of food in short periods of time or lots of empty wrappers and containers indicating consumption of large amounts of food. •Appears uncomfortable eating around others •*Appears to always be dieting •*Steals or hoards food in strange places •Creates lifestyle schedules or rituals to make time for binge sessions •*Withdraws from usual friends and activities •Shows extreme concern with body weight and shape •Has secret recurring episodes of binge eating (eating in a discrete period of time an amount of food that is much larger than most individuals would eat under similar circumstances); *feels lack of control over ability to stop eating (no control) •Disruption in normal eating behaviors, including eating throughout the day with no planned mealtimes; skipping meals or taking small portions of food at regular meals; engaging in sporadic fasting or repetitive dieting' •Developing food rituals (e.g., eating only a particular food or food group [e.g., condiments], excessive chewing, and not allowing foods to touch).

Fact Check

•Over one-half of teenage girls and one-third of teenaged boys use unhealthy weight control behaviors such as skipping meals, smoking, fasting, vomiting, or taking laxatives •42% of 1st-3rd grade girls want to be thinner • •81% of 10 year olds are afraid of being fat •The average woman is 5'4'' and weighs 140 pounds. The average supermodel is 5'11'' and weighs 117 pounds. •Americans spend over $40 billion on dieting and diet related products each year •Our obsession with external beauty, 'youngness', and defining a VERY narrow criteria for what constitutes beauty in our society has a direct correlation to the rise in E.D. among young men and women

PSYCHOLOGICAL SX of BN

•Preoccupation with eating, food, body shape, and weight •Sensitivity to comments r/t food, weight, exercise •*Low self-esteem and feelings of shame and self-loathing/guilt, particularly after eating •*Having distorted body images •Depression, anxiety, irritability

Influence of Media

•Researchers estimate that 60% of Caucasian middle school girls read at least one fashion magazine regularly •Another study of mass media magazines discovered that women's magazines had 10.5 times more advertisements and articles promoting weight loss than men's magazines did •A study of one teen adolescent magazine over the course of 20 years found that in articles about fitness or exercise plans, 74% cited "to become more attractive" as a reason to start exercising and 51% noted the need to lose weight or burn calories •The average young adolescent watches 3-4 hours of TV per day •A study of 4,294 network television commercials revealed that 1 out of every 3.8 commercials send some sort of "attractiveness message," telling viewers what is or is not attractive. These researchers estimate that the average adolescent sees over 5,260 "attractiveness messages" per year.

Anorexia Nervosa: DSM-5 Crtieria

•Restriction of energy intake that leads to significantly low body weight given the patient's age, sex, developmental, and physical health. •*Intense fear and panic over gaining weight or becoming fat/obese, or persistent behavior that prevents weight gain despite being underweight •*Disturbance in experiencing body weight or shape: Distorted perception of body weight and shape, strong influence of weight and shape on self-worth, and/or denial of the medical seriousness of one's low body weight •*Extreme feelings of low self-worth and low self-esteem - starvation is a form of punishing their own bodies *severe food restriction and they starve themselves or fast *OCD behaviors towards food/exercise, they will count how many times they have gone to the restroom, how much they've eaten, amount of exercise. However, unlike OCD, they do not have rituals *overexercise

DSM V Criteria

❖Diagnostic Criteria Recurrent episodes of binge eating and compensatory behaviors *Episodes occurring at least once a week for at least 3 months No severe weight loss as with anorexia nervosa *Binge eating: rapid, episodic, impulsive, uncontrollable ingestion of larger amount of food during short period of time Followed by feelings of guilt, remorse, self-contempt leading to purging Restraining one's intake is precondition for bouts of overeating Purging: vomiting or use of laxatives, diuretics, or emetics *Nonpurging: fasting or overexercising

Binge Eating Disorder Cont:

❖Medications to help treat depression and anxiety ❖*Psychotherapy - support, CBT, group work ❖Nutrition Counseling ❖Inpatient treatment options available