Chapter 13
Dissociative Disorders
Steven Jay Lynn, Joanna M. Berg, Scott O. Lilienfeld, Harald Merckelbach, Timo Giesbrecht, Dalena Van-Heugten-Van Der Kloet, Michelle Accardi-Ravid, Colleen Mundo, and Craig P. Polizzi
The most recent edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5; American Psychiatric Association [APA], 2013) defines dissociative disorders as conditions marked by a disruption of and/or discontinuity in the normal integration of consciousness, memory, identity, emotion, perception, body representation, motor control, and behavior” (p. 291). The presentation of dissociative disorders is often dramatic, perplexing, and highly variable, both within and across individuals. The hallmarks of dissociation are profound and often unpredictable shifts in consciousness, the sense of self, and perceptions of the environment.
DSM-5 asserts that the dissociative disorders share a common feature: They are frequently manifested in the wake of trauma and are influenced by their proximity to trauma (p. 291). Later in the chapter, we contrast the post-traumatic theory that is firmly embedded in the DSM-5 account of dissociation with a competing theory that does not conceptualize trauma as a necessary precursor to dissociation. In the course of our discussion, we will present a case study that illustrates the treatment of a patient with dissociative identity disorder (DID) and highlight controversies that have dogged the field of dissociation since the time of Janet's seminal writings on the topic (Janet, 1889/1973).
The DSM-5 (APA, 2013) identifies three major dissociative disorders that we discuss in turn—dissociative amnesia, depersonalization/derealization, and DID. We then present an overview of dissociation in general, followed by a more detailed discussion of diagnostic considerations, prevalence, assessment, and etiology specific to each of the dissociative disorders.
1. Dissociative amnesia is marked by an inability to recall important autobiographical information, usually of a traumatic or stressful nature inconsistent with ordinary forgetting. This condition most often “consists of localized or selective amnesia for a specific event or events, or generalized amnesia for identity and life history” (APA, 2013, p. 298).
2. Depersonalization/derealization disorder (DDD), formerly known as depersonalization disorder, is diagnosed on the basis of symptoms of persistent depersonalization, derealization, or both. Depersonalization symptoms include experiences of unreality; feelings of detachment or being an outside observer of one's thoughts, feelings, sensations, or actions; an unreal or absent sense of self; physical and emotional numbing; and time distortion. In contrast, derealization experiences involve feelings of unreality or detachment with respect to one's surroundings that include the experience of individuals or objects as unreal, dreamlike, foggy, visually distorted, or lifeless.
3. Dissociative identi.
Pandangan Ilmu Kedokteran Jiwa pada KESURUPAN Andri Andri
Kasus Kesurupan di Indonesia banyak dikaitkan dengan budaya. Presentasi ini mencoba melihat masalah kesurupan lebih kepada sudut pandang ilmiah. Presentasi ini disampaikan di Fakultas Psikologi Univ Mercubuana pada tanggal 23 Mei 2015
the question was about conditions under which one may be described as a deviation of personality and clearly identifying the symptoms, occurrence, diagnoses and treatment not more than six pages
INTRODUCTION
Dissociative Disorders are a group of conditions defined as psychological
disturbances that impact an individual’s ability to function and closely
overlap with psychotic disorders.
These include disturbances affecting:
Memory
Motor Control
Concept of Identity
Behaviours
Emotions
Perceptions
The symptoms of a dissociative disorder usually first develop as a
response to a traumatic event, such as abuse or military combat, to
keep those memories under control.
Stressful situations can worsen symptoms and cause problems with
functioning in everyday activities.
However, the symptoms a person experiences will depend on the
type of dissociative disorder that a person has.
TYPES OF DISSOCIATIVE DISORDER
DSM-5
Dissociative Identity Disorder (DID)
Dissociative Amnesia (Fugue)
Depersonalization/ Derealization Disorder
Other Specified Dissociative Disorder
Unspecified Dissociative Disorder
ICD-10
Dissociative Amnesia
Dissociative Fugue
Dissociative Stupor
Trance and Possession Disorders
Dissociative Motor Disorders
Dissociative Convulsions
Dissociative Anaesthesia and Sensory Loss
Mixed Dissociative (Conversion) Disorders
Other Dissociative (Conversion) Disorders:-
Ganser Syndrome
Multiple Personality
Psychogenic: Confusion and Twilight State
Dissociative (Conversion) Disorder
Dissociative Amnesia
Dissociative amnesia involves not being able to recall information about
oneself (not normal forgetting).
Dissociative amnesia is associated with having experiences of
childhood trauma, and particularly with experiences of emotional
abuse and emotional neglect.
The main symptom is memory loss that's more severe than normal
forgetfulness and that can't be explained by a medical condition.
Dissociative amnesia can be specific to events in a certain time, such
as intense combat, or more rarely, can involve complete loss of
memory about yourself.
This amnesia is usually related to a traumatic or stressful event and may be:
Localized: inability to remember all events occurring during a circumscribed
period of time.
Selective: inability to remember specific events occurring during a
circumscribed period of time.
Generalized: loss of memory encompasses everything, including one’s
identity.
Continuous: inability to recall events subsequent to a specific point in time
through the present.
Systematized: inability to recall memories related to a certain category of
information, e.g. memories related to an individual’s father.
Dissociative fugue (formerly called psychogenic fugue) is a psychological
state in which a person loses awareness of their identity or other important
autobiographical information and also engages in some form of unexpected
travel.
People who experience a dissociative fugue may suddenly find themselves
in a place, such as the beach or at work, with no memory of travelling
there.
The DSM-5 refers to dissociative fugue as a state of “bewildered
wandering.”
Dissociative Fugue
Formerly known as Mul
Research-Based Interventions: Dissociative Identity Disorder 1
THIS IS AN EXAMPLE PLEASE DO NO COPY DO NOT PLAGiarism
Research-Based Interventions: Dissociative Identity Disorder
“Dissociative identity disorder is characterized by the presence of two or more identities or personality states, each with its relatively enduring pattern of perceiving, relating to, and thinking about the environment and the self” (Vermetten, Schmahl, Lindner, Loewenstein, & Bremner, 2006). There are many characteristics used that accompany Dissociative Disorder (DID). One method to understanding would be to know how the disorders are classified and defined. DID may be conceptualized effectively using the diathesis-stress model. There are many different intervention strategies for this disorder as well. Over time researchers have discovered the most effective treatments and interventions that can be used regarding DID. When one dissociates, the person may not have conscious awareness of what is happening (Vermetten, Schmahl, Lindner, Loewenstein, & Bremner, 2006).
Peer-reviewed Articles
One limitless, longitudinal, naturalistic, and prospective study investigated childhood maltreatment (CM) in adult intimate partner violence (IPV) victims among Dissociative Disorder (DD) patients with Dissociative Identity Disorder with CM rates of 80-95% and severe dissociative symptoms (Webermann, Brand, & Chasson, 2014). The methods of this study include 275 DD outpatient therapy patients who completed a self-reported measure of dissociation (Webermann, Brand, & Chasson, 2014). Analyses assessed associations between CM typologies, trait dissociation, and IPV (Webermann, Brand, & Chasson, 2014). The results of this study include emotional and physical child abuse associated with childhood witnessing of domestic violence, physical, and emotional IPV (Webermann, Brand, & Chasson, 2014) Two-tailed independent samples t -tests and z-tests were used in this study to represent data as well. “As an effect size, odds ratios (ORs) were calculated to predict the likelihood of a participant being in an abusive adult relationship if they experienced a particular type of CM” (Webermann, Brand, & Chasson, 2014, p. 5).
A double-blind study was conducted including 15 females with DID compared to 23 without psychopathology., chosen by self-disclosure results of a questionnaire along with a structured clinical interview by psychiatrists The objective was to examine the volumetric differences between amygdala and hippocampal volumes in patients with dissociative identity disorder, a disorder that has been associated with a history of severe childhood trauma (Vermetten, Schmahl, Lindner, Loewenstein, & Bremner, 2006). These researchers used MRI to measure volumes of the amygdala and hippocampus. The results included the volume of the hippocampus being 19.2 % smaller and the amygdala being 31.6% smaller in patients with DID when compared to the other subjects without psychopath ...
Effects of trauma on implicit emotion regulation within a family system a res...Michael Changaris
This paper explores emotion regulation, family functioning, PTSD, impact of moral development and points to family therapy techniques to re-establish health in the family.
Proof version: Bishop, D., & Rutter, M. (2008). Neurodevelopmental disorders: conceptual approaches. In M. Rutter, D. Bishop, D. Pine, S. Scott, J. Stevenson, E. Taylor & A. Thapar (Eds.), Rutter's Child and Adolescent Psychiatry (pp. 32-41). Oxford: Blackwell.
From Perceived Stress to Demoralization in Parkinson Disease: A Path AnalysisDr. Robert Kohn
Objectives: The objective of this study was to determine whether depression and anxiety are mediators between perceived stress and demoralization via a loss of the cognitive map to get out of the predicament manifesting as subjective incompetence.
CompetencyAnalyze how human resource standards and practices.docxbartholomeocoombs
Competency
Analyze how human resource standards and practices within the healthcare field support organizational mission, visions, and values.
Scenario
Wynn Regional Medical Center (WRMC) is the premier hospital in your area. The hospital has been in your city for over 100 years. Over the past decade, the hospital has been losing money for various reasons, though primarily due to uncompensated care. You were recently hired as the Vice President for Human Resources at WRMC, and part of your responsibilities include presenting historical information to participants of the new employee orientation.
Instructions
Create a PowerPoint presentation detailing the changing nature of the healthcare workforce. The presentation should contain speaker notes for each slide or voiceover narration. The presentation should address the following topics and questions:
Historical information on the changing healthcare workforce
How have legislation and policies changed in the past decade?
How have patient demographics changed in the past decade (baby boomers, generation X, millennials, ethnicities)?
How have patient centric approaches changed in the past decade (use of the Internet and social media to gather health information)?
Challenges associated with the changing healthcare workforce
What are some of the challenges associated with the policy and legislative changes?
What are some challenges associated with demographic changes?
What are some of the challenges associated with patients “researching” their own health instead of going to the doctor?
Current state of healthcare
What have been some of the improvements to the healthcare system over the last decade?
Resources
This
link
has information for creating a PowerPoint presentation.
Here is a
link
to information about adding speaker notes.
Here is a
link
to information about creating a voiceover narration using Screencast-O-Matic.
GRADING RUBRICS:
1.Clear and thorough explanation of the history of the changing healthcare workforce. Includes comprehensive descriptions with multiple supporting examples for each of the SUB-BULLET POINTS.
2. Clear and thorough discussion of the challenges associated with the changing healthcare workforce. Includes comprehensive descriptions with multiple supporting examples for each of the SUB-BULLET POINTS.
3. Comprehensive analysis of the current state of healthcare.
Includes a clear and thorough assessment of improvements to the healthcare system over the last decade and supports assertions with multiple supporting examples.
.
CompetencyAnalyze financial statements to assess performance.docxbartholomeocoombs
Competency
Analyze financial statements to assess performance and to ensure organizational improvement and long-term viability
.
Scenario
In an ongoing effort to explore the feasibility of expanding services into rural areas of the state, leadership at Memorial Hospital has determined that conducting a review of its financial condition will be essential to ensuring the organization’s ability to successfully achieve its expansion goals.
Instructions
The CFO has provided you with a copy of the organization’s
financial statements
. This information will be critical in evaluating the organization’s financial capacity to support the proposed expansion of services into the rural areas of the state.
You are asked to review these financial statements (which include the Income Statement, Statement of Cash Flows, and the Balance Sheet) and prepare an executive summary outlining the financial strength of the organization and evidence to support the expansion. Your executive summary should include the following:
An overview of the issue.
A review of critical financial ratios (Liquidity, Solvency, Profitability, and Efficiency) based on financial statements.
Inferences of forecasts, estimates, interpretations, and conclusions based on the key ratios.
Provide a recommendation based on ration analysis.
Resources
This
link
has information for creating an executive summary.
Grading Rubric:
1.
Comprehensive identification of summary of the issue. Includes multiple examples or supporting details.
2. Clear and thorough review of critical financial ratios--Liquidity, Solvency, Profitability, and Efficiency--based on financial statements. Includes multiple examples or supporting details per topic.
3. Clear and thorough inferences of forecasts, estimates, interpretations, and conclusions based on the key ratios. Includes multiple examples or supporting details per topic.
4. Comprehensive recommendation, based on ration analysis. Includes multiple examples or supporting details.
.
More Related Content
Similar to Chapter 13Dissociative DisordersSteven Jay Lynn, Joanna M. Ber.docx
Pandangan Ilmu Kedokteran Jiwa pada KESURUPAN Andri Andri
Kasus Kesurupan di Indonesia banyak dikaitkan dengan budaya. Presentasi ini mencoba melihat masalah kesurupan lebih kepada sudut pandang ilmiah. Presentasi ini disampaikan di Fakultas Psikologi Univ Mercubuana pada tanggal 23 Mei 2015
the question was about conditions under which one may be described as a deviation of personality and clearly identifying the symptoms, occurrence, diagnoses and treatment not more than six pages
INTRODUCTION
Dissociative Disorders are a group of conditions defined as psychological
disturbances that impact an individual’s ability to function and closely
overlap with psychotic disorders.
These include disturbances affecting:
Memory
Motor Control
Concept of Identity
Behaviours
Emotions
Perceptions
The symptoms of a dissociative disorder usually first develop as a
response to a traumatic event, such as abuse or military combat, to
keep those memories under control.
Stressful situations can worsen symptoms and cause problems with
functioning in everyday activities.
However, the symptoms a person experiences will depend on the
type of dissociative disorder that a person has.
TYPES OF DISSOCIATIVE DISORDER
DSM-5
Dissociative Identity Disorder (DID)
Dissociative Amnesia (Fugue)
Depersonalization/ Derealization Disorder
Other Specified Dissociative Disorder
Unspecified Dissociative Disorder
ICD-10
Dissociative Amnesia
Dissociative Fugue
Dissociative Stupor
Trance and Possession Disorders
Dissociative Motor Disorders
Dissociative Convulsions
Dissociative Anaesthesia and Sensory Loss
Mixed Dissociative (Conversion) Disorders
Other Dissociative (Conversion) Disorders:-
Ganser Syndrome
Multiple Personality
Psychogenic: Confusion and Twilight State
Dissociative (Conversion) Disorder
Dissociative Amnesia
Dissociative amnesia involves not being able to recall information about
oneself (not normal forgetting).
Dissociative amnesia is associated with having experiences of
childhood trauma, and particularly with experiences of emotional
abuse and emotional neglect.
The main symptom is memory loss that's more severe than normal
forgetfulness and that can't be explained by a medical condition.
Dissociative amnesia can be specific to events in a certain time, such
as intense combat, or more rarely, can involve complete loss of
memory about yourself.
This amnesia is usually related to a traumatic or stressful event and may be:
Localized: inability to remember all events occurring during a circumscribed
period of time.
Selective: inability to remember specific events occurring during a
circumscribed period of time.
Generalized: loss of memory encompasses everything, including one’s
identity.
Continuous: inability to recall events subsequent to a specific point in time
through the present.
Systematized: inability to recall memories related to a certain category of
information, e.g. memories related to an individual’s father.
Dissociative fugue (formerly called psychogenic fugue) is a psychological
state in which a person loses awareness of their identity or other important
autobiographical information and also engages in some form of unexpected
travel.
People who experience a dissociative fugue may suddenly find themselves
in a place, such as the beach or at work, with no memory of travelling
there.
The DSM-5 refers to dissociative fugue as a state of “bewildered
wandering.”
Dissociative Fugue
Formerly known as Mul
Research-Based Interventions: Dissociative Identity Disorder 1
THIS IS AN EXAMPLE PLEASE DO NO COPY DO NOT PLAGiarism
Research-Based Interventions: Dissociative Identity Disorder
“Dissociative identity disorder is characterized by the presence of two or more identities or personality states, each with its relatively enduring pattern of perceiving, relating to, and thinking about the environment and the self” (Vermetten, Schmahl, Lindner, Loewenstein, & Bremner, 2006). There are many characteristics used that accompany Dissociative Disorder (DID). One method to understanding would be to know how the disorders are classified and defined. DID may be conceptualized effectively using the diathesis-stress model. There are many different intervention strategies for this disorder as well. Over time researchers have discovered the most effective treatments and interventions that can be used regarding DID. When one dissociates, the person may not have conscious awareness of what is happening (Vermetten, Schmahl, Lindner, Loewenstein, & Bremner, 2006).
Peer-reviewed Articles
One limitless, longitudinal, naturalistic, and prospective study investigated childhood maltreatment (CM) in adult intimate partner violence (IPV) victims among Dissociative Disorder (DD) patients with Dissociative Identity Disorder with CM rates of 80-95% and severe dissociative symptoms (Webermann, Brand, & Chasson, 2014). The methods of this study include 275 DD outpatient therapy patients who completed a self-reported measure of dissociation (Webermann, Brand, & Chasson, 2014). Analyses assessed associations between CM typologies, trait dissociation, and IPV (Webermann, Brand, & Chasson, 2014). The results of this study include emotional and physical child abuse associated with childhood witnessing of domestic violence, physical, and emotional IPV (Webermann, Brand, & Chasson, 2014) Two-tailed independent samples t -tests and z-tests were used in this study to represent data as well. “As an effect size, odds ratios (ORs) were calculated to predict the likelihood of a participant being in an abusive adult relationship if they experienced a particular type of CM” (Webermann, Brand, & Chasson, 2014, p. 5).
A double-blind study was conducted including 15 females with DID compared to 23 without psychopathology., chosen by self-disclosure results of a questionnaire along with a structured clinical interview by psychiatrists The objective was to examine the volumetric differences between amygdala and hippocampal volumes in patients with dissociative identity disorder, a disorder that has been associated with a history of severe childhood trauma (Vermetten, Schmahl, Lindner, Loewenstein, & Bremner, 2006). These researchers used MRI to measure volumes of the amygdala and hippocampus. The results included the volume of the hippocampus being 19.2 % smaller and the amygdala being 31.6% smaller in patients with DID when compared to the other subjects without psychopath ...
Effects of trauma on implicit emotion regulation within a family system a res...Michael Changaris
This paper explores emotion regulation, family functioning, PTSD, impact of moral development and points to family therapy techniques to re-establish health in the family.
Proof version: Bishop, D., & Rutter, M. (2008). Neurodevelopmental disorders: conceptual approaches. In M. Rutter, D. Bishop, D. Pine, S. Scott, J. Stevenson, E. Taylor & A. Thapar (Eds.), Rutter's Child and Adolescent Psychiatry (pp. 32-41). Oxford: Blackwell.
From Perceived Stress to Demoralization in Parkinson Disease: A Path AnalysisDr. Robert Kohn
Objectives: The objective of this study was to determine whether depression and anxiety are mediators between perceived stress and demoralization via a loss of the cognitive map to get out of the predicament manifesting as subjective incompetence.
CompetencyAnalyze how human resource standards and practices.docxbartholomeocoombs
Competency
Analyze how human resource standards and practices within the healthcare field support organizational mission, visions, and values.
Scenario
Wynn Regional Medical Center (WRMC) is the premier hospital in your area. The hospital has been in your city for over 100 years. Over the past decade, the hospital has been losing money for various reasons, though primarily due to uncompensated care. You were recently hired as the Vice President for Human Resources at WRMC, and part of your responsibilities include presenting historical information to participants of the new employee orientation.
Instructions
Create a PowerPoint presentation detailing the changing nature of the healthcare workforce. The presentation should contain speaker notes for each slide or voiceover narration. The presentation should address the following topics and questions:
Historical information on the changing healthcare workforce
How have legislation and policies changed in the past decade?
How have patient demographics changed in the past decade (baby boomers, generation X, millennials, ethnicities)?
How have patient centric approaches changed in the past decade (use of the Internet and social media to gather health information)?
Challenges associated with the changing healthcare workforce
What are some of the challenges associated with the policy and legislative changes?
What are some challenges associated with demographic changes?
What are some of the challenges associated with patients “researching” their own health instead of going to the doctor?
Current state of healthcare
What have been some of the improvements to the healthcare system over the last decade?
Resources
This
link
has information for creating a PowerPoint presentation.
Here is a
link
to information about adding speaker notes.
Here is a
link
to information about creating a voiceover narration using Screencast-O-Matic.
GRADING RUBRICS:
1.Clear and thorough explanation of the history of the changing healthcare workforce. Includes comprehensive descriptions with multiple supporting examples for each of the SUB-BULLET POINTS.
2. Clear and thorough discussion of the challenges associated with the changing healthcare workforce. Includes comprehensive descriptions with multiple supporting examples for each of the SUB-BULLET POINTS.
3. Comprehensive analysis of the current state of healthcare.
Includes a clear and thorough assessment of improvements to the healthcare system over the last decade and supports assertions with multiple supporting examples.
.
CompetencyAnalyze financial statements to assess performance.docxbartholomeocoombs
Competency
Analyze financial statements to assess performance and to ensure organizational improvement and long-term viability
.
Scenario
In an ongoing effort to explore the feasibility of expanding services into rural areas of the state, leadership at Memorial Hospital has determined that conducting a review of its financial condition will be essential to ensuring the organization’s ability to successfully achieve its expansion goals.
Instructions
The CFO has provided you with a copy of the organization’s
financial statements
. This information will be critical in evaluating the organization’s financial capacity to support the proposed expansion of services into the rural areas of the state.
You are asked to review these financial statements (which include the Income Statement, Statement of Cash Flows, and the Balance Sheet) and prepare an executive summary outlining the financial strength of the organization and evidence to support the expansion. Your executive summary should include the following:
An overview of the issue.
A review of critical financial ratios (Liquidity, Solvency, Profitability, and Efficiency) based on financial statements.
Inferences of forecasts, estimates, interpretations, and conclusions based on the key ratios.
Provide a recommendation based on ration analysis.
Resources
This
link
has information for creating an executive summary.
Grading Rubric:
1.
Comprehensive identification of summary of the issue. Includes multiple examples or supporting details.
2. Clear and thorough review of critical financial ratios--Liquidity, Solvency, Profitability, and Efficiency--based on financial statements. Includes multiple examples or supporting details per topic.
3. Clear and thorough inferences of forecasts, estimates, interpretations, and conclusions based on the key ratios. Includes multiple examples or supporting details per topic.
4. Comprehensive recommendation, based on ration analysis. Includes multiple examples or supporting details.
.
CompetencyAnalyze ethical and legal dilemmas that healthcare.docxbartholomeocoombs
Competency
Analyze ethical and legal dilemmas that healthcare workers may encounter in the medical field.
Instructions
You have recently been promoted to Health Services Manager at Three Mountains Regional Hospital, a small hospital located in a mid-size city in the Midwest. Three Mountains is a general medical and surgical facility with 400 beds. Last year there were approximately 62,000 emergency visits and 15,000 admissions. More than 6,000 outpatient and 10,000 inpatient surgeries were performed.
An important aspect of the provider/patient relationship pertains to open communication and trust. Patients want to know that their doctors and the support staff associated with their care understand their wishes and will abide by them. Ideally, these conversations happen well before an emergency or procedure takes place; however, often times this information is missing from a patient's file. As part of Three Mountains' initiative to build trust with their patients, an increased emphasis has been placed on obtaining living wills from the patient as part of the intake process to ensure that the healthcare team has written directives of the patient's wishes in case of incapacitation. You will be creating a living will for a patient and provide educational information as to why the patient should fill it out during the admission process before a procedure.
Introduction:
Explain the definition of a living will and its key components. This section will provide an educational overview of the document for the patient.
Living Will Template:
Create a living will that can serve as a template to the patients. This should cover the basic treatment issues such as resuscitation, feeding tubes, ventilation, organ and tissue donations, etc. Provide instructions in the template that can be easily altered, depending on each patient's wishes.
Summary:
In this section, you will discuss the importance of this document and encourage patients to complete it. Address how this document ensures that a patient's wishes are known and followed by the healthcare team.
NOTE
- APA formatting and proper grammar, punctuation, and form required. APA help is available
here.
.
CompetencyAnalyze ethical and legal dilemmas that healthcare wor.docxbartholomeocoombs
Competency
Analyze ethical and legal dilemmas that healthcare workers may encounter in the medical field.
Instructions
You have recently been promoted to Health Services Manager at Three Mountains Regional Hospital, a small hospital located in a mid-size city in the Midwest. Three Mountains is a general medical and surgical facility with 400 beds. Last year there were approximately 62,000 emergency visits and 15,000 admissions. More than 6,000 outpatient and 10,000 inpatient surgeries were performed.
An important aspect of the provider/patient relationship pertains to open communication and trust. Patients want to know that their doctors and the support staff associated with their care understand their wishes and will abide by them. Ideally, these conversations happen well before an emergency or procedure takes place; however, often times this information is missing from a patient's file. As part of Three Mountains' initiative to build trust with their patients, an increased emphasis has been placed on obtaining living wills from the patient as part of the intake process to ensure that the healthcare team has written directives of the patient's wishes in case of incapacitation. You will be creating a living will for a patient and provide educational information as to why the patient should fill it out during the admission process before a procedure.
Introduction:
Explain the definition of a living will and its key components. This section will provide an educational overview of the document for the patient.
Living Will Template:
Create a living will that can serve as a template to the patients. This should cover the basic treatment issues such as resuscitation, feeding tubes, ventilation, organ and tissue donations, etc. Provide instructions in the template that can be easily altered, depending on each patient's wishes.
Summary:
In this section, you will discuss the importance of this document and encourage patients to complete it. Address how this document ensures that a patient's wishes are known and followed by the healthcare team.
NOTE
- APA formatting and proper grammar, punctuation, and form required.
.
CompetencyAnalyze collaboration tools to support organizatio.docxbartholomeocoombs
Competency
Analyze collaboration tools to support organizational goals.
Scenario
You are a new manager at Elliot Building Supplies International who has seen huge success in managing your global team remotely. This success has been shown in the team outcomes/production and employee satisfaction and engagement. Senior leadership has taken notice of your success and has asked you to create a presentation to share with your peers, who also manage remotely, that explains the best collaboration tools for remote teams. Also, you will explain the best way to manage effectively and create a motivating and satisfying work environment that supports collaboration.
Instructions
You will need to include the following in your PowerPoint presentation.
Presentation welcome/introduction slide.
Collaboration tools that you have used to be successful.
This should include at least 4 different types of tools.
Each type should be explained in detail, along with the benefits it provides.
Critical skills to successfully manage remote employees.
Closing slide to share final thoughts and ideas.
.
Competency Checklist and Professional Development Resources .docxbartholomeocoombs
Competency Checklist and Professional Development Resources
An important and yet often overlooked function of leadership in an early childhood program is the ability to positively influence the people in the program. For this group assignment, consider the characteristics of a leader who can support and lead teachers in reflective teaching. This type of self-reflection is the first step to understanding how a supervisor supports teachers to accomplish their goals through mentoring. For this assignment, your group will need to address the following two components:
Part 1
: Consider the following question as your group completes the competency checklist below: What might be evidence that a teacher leader possesses the competence to also be a mentor? You are encouraged to evenly divide the competencies among your group, so that each member contributes to providing brief examples of interactions while highlighting the characteristic(s) that demonstrates each competency. While this portion can be completed independently, you should then collaborate to ensure that each group member provides feedback before submitting the full collaborative document.
Competency Checklist
Competency
Describe an example of a teacher-leader with children (when acting as a teacher)
Describe an example of a teacher-leader with adults (when acting as a supervisor)
Listens well, does not interrupt, and respects the pace of the other person
Is able to wait for others to discover solutions, form own ideas, and reflect
Asks questions that encourage details
Is aware of and comfortable with his or her feelings and the emotions of others
Is responsive to others
Guides, nurtures, supports, and empathizes
Integrates emotion and intellect
Fosters reflection or wondering by others
Is aware of how others’ reactions affect a process of dialogue and reflection, including sensitivity to bias and cultural context
Is willing to have consistent and predictable meeting times and places
Is flexible and available
Is able to form trusting relationships
Part 2:
Professional Development Resources Document
–Early childhood programs have numerous curriculum options which may contribute to a need to support teachers and staff in a curriculum context they are not familiar with. Therefore, as we prepare to support protégés, we can refer to the National Association of the Education of Young Children core standards for professional development, to promote the use of best practices. These six core standards, briefly describe what early childhood professionals should know and be able to do. After reading each of the
NAEYC Standards for Early Childhood Professional Preparation Programs (Links to an external site.)
, focus on the first four standards:
STANDARD 1.
PROMOTING CHILD DEVELOPMENT AND LEARNING
STANDARD 2.
BUILDING FAMILY AND COMMUNITY RELATIONSHIPS
STANDARD 3.
OBSERVING, DOCUMENTING, AND ASSESSING TO SUPPORT YOUNG CHILDREN AND FAMILIES
STANDARD 4.
US.
Competency 6 Enagage with Communities and Organizations (3 hrs) (1 .docxbartholomeocoombs
Competency 6: Enagage with Communities and Organizations (3 hrs) (1 to 2 Pages)
Behavior: use empathy, reflection, and interpersonal skills to effectively engage diverse clients and constituencies.
For this assignment, you are to explore how your community is addressing the needs of its citizens during the CoVID 19 situation. Explore how you can consult and connect with community leaders and organizations to be a part of solutions in your community. Provide a detailed account of your exploration of community needs, as well as how you participated at the community level to address the needs of your community.
.
Competency 2 Examine the organizational behavior within busines.docxbartholomeocoombs
Competency 2: Examine the organizational behavior within business systems
Provide the name of the corporation you will be using as the basis for this project.
Provide the organization’s purpose or mission statement.
Describe the organization's industry.
Provide the name and position of the person interviewed during this portion of the assignment (indicate as much pertinent information (e.g., length of service with company, previous roles in the company, educational background, etc.).
Provide the list of interview questions you asked the manager/executive.
Indicate which two - three of the following concepts from this competency that you intend to evaluate the organization/team on and describe the company’s/team’s current situation with each topic you’ve selected:
Motivational theories
Psychological contract
Job design
Use of evaluation, feedback and rewards
Misbehavior
Individual or organizational stress
Provide citations in APA format for any references
.
CompetenciesEvaluate the challenges and benefits of employ.docxbartholomeocoombs
Competencies
Evaluate the challenges and benefits of employing a diverse workforce.
Design a plan for conducting business and managing employees in a global society.
Critique the actions of organizations as they integrate diverse perspectives into their cultures.
Evaluate the role of identity, diverse segments, and cultural backgrounds within organizations.
Attribute different cultural perspectives to current social-cultural dimensions.
Analyze the importance of managing a diverse workforce.
Scenario Information
Your company has been nominated for a national diversity award associated with your efforts and dedication to diversity initiatives in the workplace and their impact on the organization and community. You have been asked to summarize your efforts for the year in a slide presentation for the diversity committee who selects the winner. Be sure to include details of the changes you made in your organization and the impact the changes made.
Instructions
As part of your nomination, you have been asked to create a slide presentation including a voice recording for your entry (Voice Recording not needed). Remember your audience when giving your presentation and include the following slides:
Title slide
Highlighting the importance of workplace diversity
Discussing the points that were included in your diversity plan
Describing how culture and inclusion impact your organization
Providing examples of how diverse workgroups work together in the workplace
Gives examples of strategies used to incorporate Hofstede's cultural dimensions in a global workforce
Provides best practices for managers associated with managing a diverse, global workforce
Conclusion slide that includes a summary of why you should win this award
Any additional, relevant information
References
.
CompetenciesDescribe the supply chain management principle.docxbartholomeocoombs
Competencies
Describe the supply chain management principles through the flow of information, materials, services, and resources.
Analyze the external and internal drivers that influence supply chain principles.
Evaluate supply chain management operational best practices.
Compare the nature of logistics operations and services in both international and domestic contexts.
Apply strategic supply chain management to logistics systems.
Analyze different software systems and technology strategies used in supply chain management.
Scenario
You have just been promoted to Senior Analyst at Mitchell Consulting, a firm that specializes in providing managerial expertise in supply chain management. After completing many assignments under the supervision of a Senior Analyst, your role now allows you to make selections for clients. You are assigned a new client, Scent
Solution
s. Your new manager, Partner Ronda Anderson, has directed you to work on this case and provide analysis and options to resolve the problems directly to the client.
Scent
.
CompetenciesABCDF1.1 Create oral, written, or visual .docxbartholomeocoombs
Competencies
A
B
C
D
F
1.1: Create oral, written, or visual communications appropriate to the audience, purpose, and context.
4 points
Key Criteria: Tailors communication to purpose, context, and target audience. Clearly articulates the thesis and purpose, and supports the thesis and purpose with authentic and appropriate evidence. Provides smooth transitions and leaves no awkward gaps from point to point. Shows coherent progress from the introduction to the conclusion with no unnecessary sections.
3 points
Key Criteria: Tailors communication to purpose, context, and target audience. Articulates the thesis and purpose, and supports the thesis and purpose with authentic and appropriate evidence. Generally provides smooth transitions and leaves few awkward gaps from point to point. Shows identifiable progress from the introduction to the conclusion with no unnecessary sections.
2 points
Key Criteria: Considers the purpose, context, and target audience. Articulates the thesis and purpose, and shows some evidence supporting both. Some transitions are not smooth, and there are occasional gaps or awkward connections from point to point. There is a sense of progress from the introduction through the conclusion, but the organization may not be completely clear.
1 point
Key Criteria: Does not tailor communication well in terms of purpose, context, and target audience. Provides a weak thesis, unclear purpose, and little or no evidence to support points. Transitions may be rough or nonexistent, and there are significant gaps or connections between points that leave sections incomprehensible. Progress from the introduction through the conclusion is difficult to decipher, and there may be some material that is unrelated to thesis and purpose.
0 points
Key Criteria: Does not tailor communication in terms of purpose, context, and target audience. Lacks a good thesis and has little or no evidence to support a thesis. Transitions are rough or nonexistent, and there are few discernable connections from point to point. There is no identifiable progress from the introduction through the conclusion, and/or there is substantial material that is unrelated to thesis and purpose.
1.2: Communicate using appropriate writing conventions, including spelling, grammar, mechanics, word choice, and format.
4 points
Uses a format that is highly appropriate to the writing task and carefully tailors the style and tone to the specific audience. Aligns both the writing style and grammar usage to standards appropriate to the task.
3 points
Uses a format that is appropriate to the writing task and tailors the style and tone to the specific audience. Aligns both the writing style and grammar usage to standards appropriate to the task.
2 points
Generally has a clear purpose, but there may be a gap between the format used and the writing task. Fails to fully align the style and tone to the audience, or fails to fully define the audience for the writing task. Has some style or grammar.
COMPETENCIES734.3.4 Healthcare Utilization and Finance.docxbartholomeocoombs
COMPETENCIES
734.3.4
:
Healthcare Utilization and Finance
The graduate analyzes financial implications related to healthcare delivery, reimbursement, access, and national initiatives.
INTRODUCTION
It is essential that nurses understand the issues related to healthcare financing, including local, state, and national healthcare policies and initiatives that affect healthcare delivery. As a patient advocate, the professional nurse is in a position to work with patients and families to access available resources to meet their healthcare needs.
REQUIREMENTS
Your submission must be your original work. No more than a combined total of 30% of the submission and no more than a 10% match to any one individual source can be directly quoted or closely paraphrased from sources, even if cited correctly. An originality report is provided when you submit your task that can be used as a guide.
You must use the rubric to direct the creation of your submission because it provides detailed criteria that will be used to evaluate your work. Each requirement below may be evaluated by more than one rubric aspect. The rubric aspect titles may contain hyperlinks to relevant portions of the course.
A. Compare the U.S. healthcare system with the healthcare system of Great Britain, Japan, Germany, or Switzerland, by doing the following:
1. Identify
one
country from the following list whose healthcare system you will compare to the U.S. healthcare system: Great Britain, Japan, Germany, or Switzerland.
2. Compare access between the
two
healthcare systems for children, people who are unemployed, and people who are retired.
a. Discuss coverage for medications in the two healthcare systems.
b. Determine the requirements to get a referral to see a specialist in the two healthcare systems.
c. Discuss coverage for preexisting conditions in the two healthcare systems.
3. Explain
two
financial implications for patients with regard to the healthcare delivery differences between the two countries (i.e.; how are the patients financially impacted).
B. Acknowledge sources, using in-text citations and references, for content that is quoted, paraphrased, or summarized.
C. Demonstrate professional communication in the content and presentation of your submission.
File Restrictions
File name may contain only letters, numbers, spaces, and these symbols: ! - _ . * ' ( )
File size limit: 200 MB
File types allowed: doc, docx, rtf, xls, xlsx, ppt, pptx, odt, pdf, txt, qt, mov, mpg, avi, mp3, wav, mp4, wma, flv, asf, mpeg, wmv, m4v, svg, tif, tiff, jpeg, jpg, gif, png, zip, rar, tar, 7z
RUBRIC
A1:COUNTRY TO COMPARE
NOT EVIDENT
A country for comparison is not identified.
APPROACHING COMPETENCE
The identified country for comparison is not from the given list.
COMPETENT
The identified country for comparison is from the given list.
A2:ACCESS
NOT EVIDENT
A comparison of healthcare system access is not provided.
APPROACHING COMPETENCE
The comparison does not acc.
Competencies and KnowledgeWhat competencies were you able to dev.docxbartholomeocoombs
Competencies and Knowledge
What competencies were you able to develop in researching and writing the course Comprehensive Project? How did you leverage knowledge gained in the assignments (Units 1–4) in completing the Comprehensive Project? How will these competencies and knowledge support your career advancement in management
.
Competencies and KnowledgeThis assignment has 2 parts.docxbartholomeocoombs
Competencies and Knowledge
This assignment has 2 parts:
What competencies were you able to develop in researching and writing the course Comprehensive Project? How did you leverage knowledge gained in the intellipath assignments (Units 1- 4) in completing the Comprehensive Project? How will these competencies and knowledge support your career advancement in management?
Discuss the similarities and differences between shareholder wealth maximization and stakeholder wealth maximization.
.
Competencies and KnowledgeThis assignment has 2 partsWhat.docxbartholomeocoombs
Competencies and Knowledge
This assignment has 2 parts:
What competencies were you able to develop in researching and writing the course Comprehensive Project? How did you leverage knowledge gained in the intellipath assignments (Units 1- 4) in completing the Comprehensive Project? How will these competencies and knowledge support your career advancement in management?
Discuss the similarities and differences between shareholder wealth maximization and stakeholder wealth maximization.
.
Competences, Learning Theories and MOOCsRecent Developments.docxbartholomeocoombs
Competences, Learning Theories and MOOCs:
Recent Developments in Lifelong Learning
Karl Steffens
Introduction
We think of our societies as ‘knowledge societies’ in which lifelong learning is
becoming increasingly important. Lifelong learning refers to the idea that people
not only learn in schools and universities, but also in non-formal and informal
ways during their lifespan.The concepts of lifelong learning and lifelong education
began to enter the discourse on educational policies in the late 1960s (Tuijnman
& Boström, 2002). However, these are related, but distinct concepts. As Lee (2014,
p. 472) notes ‘the terminological change (from lifelong education, continuing
education and adult education, to lifelong learning) reflects a conceptual departure
from the idea of organised educational provision to that of a more individualised
pursuit of learning’.
One of the first important documents on lifelong learning was the report of the
International Commission on the Development of Education to UNESCO in
1972, titled ‘Learning to be. The world of education today and tomorrow’. In his
introductory letter to the Director-General of UNESCO, the chairman of the
Commission, Edgar Faure, stated that the work of the Commission was based on
four assumptions (see Elfert pp. and Carneiro pp. in this issue). The first was
related to the idea that there was an international community which was united by
common aspirations and the second was the belief in democracy and in education
as its keystones. The third was ‘that the aim of development is the complete
fulfilment of man, in all the richness of his personality, the complexity of his forms
of expression and his various commitments — as individual, member of a family
and of a community, citizen and producer, inventor of techniques and creative
dreamer’. The last assumption was that ‘only an over-all, lifelong education can
produce the kind of complete man, the need for whom is increasing with the
continually more stringent constraints tearing the individual asunder’ (Faure,
1972, p. vi).
Following the Faure Report, the UNESCO Institute for Education, which
was founded in Germany in 1951, started to focus on lifelong learning and
subsequently became the UNESCO Institute for Lifelong Learning (UIL, http://
uil.unesco.org/home/). It was under its leadership that a formal model of lifelong
education was developed and published in the book ‘Towards a System of Life-
long Education’ (Cropley, 1980). The concept of lifelong learning also became
manifest in the ‘Education for All’ (EFA) agenda that was launched at the World
Conference on Education for All which took place in Jomtien (Thailand) in
1990 (Inter-Agency Commission, 1990). Ten years later, at the World Education
Forum in Dakar (Senegal) in 2000, the Dakar Framework for Action was
designed ‘to enable all individuals to realize their right to learn and to fulfil their
responsibility to contribute to the development of their society’ (UNESCO,
2000, p..
Compensation & Benefits Class 700 words with referencesA stra.docxbartholomeocoombs
Compensation & Benefits Class 700 words with references
A strategic purpose for a well-blended compensation program, one that includes various types of direct compensation, is gaining employee commitment and productivity. One of the most effective tactics for this strategy is designing a process for linking individual achievement to organizational goals.
Prepare a report to senior leaders addressing the following:
·
Explain the concept of tying performance to organizational goals.
·
Describe the different types of individual and group-level performance measurements.
·
What are the advantages and disadvantages of individual versus group-level performance recognition?
·
Discuss the options an organization has to link individual or group monetary rewards to organizational success.
·
Develop recommendations for how to implement, monitor, and evaluate such a program.
.
Compensation, Benefits, Reward & Recognition Plan for V..docxbartholomeocoombs
Compensation, Benefits, Reward & Recognition Plan for V.P. Operations
Learning Team B
HRM 595
December 19, 2017
Rosalie M. Lopez
Running head: COMPENSATION, BENEFITS, REWARD & RECOGNITION PLAN
1
COMPENSATION, BENEFITS, REWARD & RECOGNITION PLAN
2
Compensation, Benefits, Reward & Recognition Plan for V.P. Operations
Introduction
Base Salary Range
For the position of VP of Operations, the National Average Salary is $122,624. In San Francisco, the average is higher and placed at $155,946. This amount is 16% higher than the National Average (Payscale, 2016). The reason for this increase is because of experience and geography. These are the two prime factors that impact the pay scale. Another major factor is the employer. Most employers base their decision to hire an individual on the experience they bring with them. Of course, with more experience, higher pay is required. With our company cutting cost a less experienced individual would be the best fit for the position.
Standard Employee Benefit
In many cases, your employee benefits could be the turning point for a prospective employee. This benefit is a vital portion of any employee packet. These valuable benefits are used as a blanket of security in the case of any sickness, injury, unemployment, old age, or death (Gomez-Mejia, Balkin & Cardy, 2015, p. 362). There is a significant difference between incentives and benefits: benefits are financial and nonfinancial compensations that are indirect to the employee. To have a competitive strategy Blossoms Up! must align their profits with the compensation package that has been already put in place. This action will help provide flexibility to the amount and the benefits available (Gomez-Mejia et al., 2015).
There are also some benefits that most companies are legally obligated to provide. Three benefits are required regardless of the number of employees that the company has. These interests involve social security, workers compensation, and unemployment insurance (Gomez-Mejia et al., 2015). Other laws must be adhered to when dealing with a certain number of individuals. When a company has 50 or more employee they must have the Family and Medical Leave Act in place and since its induction in 2015 the Affordable Care Act for Health Insurance for companies with 20 or more employees. For the health insurance to be considered standard medical, vision and dental plans must be made available to the business. These programs that must be regarded as being under the Health Maintenance Organization (HMO) or a Preferred Provider Organization (PPO) (Gomez-Mejia et al., 2015).
There are some voluntary benefits that we can include. We are already looking into adding a pension package using the Defined Contribution Plan as well as the 401(K) plan (Gomez-Mejia et al., 2015). Life insurance is another excellent benefit that could be added to the package as well as short-term and long-term disability insurance. Adding Vacation and PTO, and Holiday pay is .
Compete the following tablesTheoryKey figuresKey concepts o.docxbartholomeocoombs
Compete the following tables:
Theory
Key figures
Key concepts of personality formation
Explanation of the disordered personality
Scientific credibility
Comprehensiveness
Applicability
Attachment
Complete the following...200-300 words..
Is Freud's theory a viable theory for this century?
Provide reasons for
your
view.
.
A review of the growth of the Israel Genealogy Research Association Database Collection for the last 12 months. Our collection is now passed the 3 million mark and still growing. See which archives have contributed the most. See the different types of records we have, and which years have had records added. You can also see what we have for the future.
This presentation includes basic of PCOS their pathology and treatment and also Ayurveda correlation of PCOS and Ayurvedic line of treatment mentioned in classics.
Macroeconomics- Movie Location
This will be used as part of your Personal Professional Portfolio once graded.
Objective:
Prepare a presentation or a paper using research, basic comparative analysis, data organization and application of economic information. You will make an informed assessment of an economic climate outside of the United States to accomplish an entertainment industry objective.
it describes the bony anatomy including the femoral head , acetabulum, labrum . also discusses the capsule , ligaments . muscle that act on the hip joint and the range of motion are outlined. factors affecting hip joint stability and weight transmission through the joint are summarized.
The simplified electron and muon model, Oscillating Spacetime: The Foundation...RitikBhardwaj56
Discover the Simplified Electron and Muon Model: A New Wave-Based Approach to Understanding Particles delves into a groundbreaking theory that presents electrons and muons as rotating soliton waves within oscillating spacetime. Geared towards students, researchers, and science buffs, this book breaks down complex ideas into simple explanations. It covers topics such as electron waves, temporal dynamics, and the implications of this model on particle physics. With clear illustrations and easy-to-follow explanations, readers will gain a new outlook on the universe's fundamental nature.
Executive Directors Chat Leveraging AI for Diversity, Equity, and InclusionTechSoup
Let’s explore the intersection of technology and equity in the final session of our DEI series. Discover how AI tools, like ChatGPT, can be used to support and enhance your nonprofit's DEI initiatives. Participants will gain insights into practical AI applications and get tips for leveraging technology to advance their DEI goals.
বাংলাদেশের অর্থনৈতিক সমীক্ষা ২০২৪ [Bangladesh Economic Review 2024 Bangla.pdf] কম্পিউটার , ট্যাব ও স্মার্ট ফোন ভার্সন সহ সম্পূর্ণ বাংলা ই-বুক বা pdf বই " সুচিপত্র ...বুকমার্ক মেনু 🔖 ও হাইপার লিংক মেনু 📝👆 যুক্ত ..
আমাদের সবার জন্য খুব খুব গুরুত্বপূর্ণ একটি বই ..বিসিএস, ব্যাংক, ইউনিভার্সিটি ভর্তি ও যে কোন প্রতিযোগিতা মূলক পরীক্ষার জন্য এর খুব ইম্পরট্যান্ট একটি বিষয় ...তাছাড়া বাংলাদেশের সাম্প্রতিক যে কোন ডাটা বা তথ্য এই বইতে পাবেন ...
তাই একজন নাগরিক হিসাবে এই তথ্য গুলো আপনার জানা প্রয়োজন ...।
বিসিএস ও ব্যাংক এর লিখিত পরীক্ষা ...+এছাড়া মাধ্যমিক ও উচ্চমাধ্যমিকের স্টুডেন্টদের জন্য অনেক কাজে আসবে ...
Safalta Digital marketing institute in Noida, provide complete applications that encompass a huge range of virtual advertising and marketing additives, which includes search engine optimization, virtual communication advertising, pay-per-click on marketing, content material advertising, internet analytics, and greater. These university courses are designed for students who possess a comprehensive understanding of virtual marketing strategies and attributes.Safalta Digital Marketing Institute in Noida is a first choice for young individuals or students who are looking to start their careers in the field of digital advertising. The institute gives specialized courses designed and certification.
for beginners, providing thorough training in areas such as SEO, digital communication marketing, and PPC training in Noida. After finishing the program, students receive the certifications recognised by top different universitie, setting a strong foundation for a successful career in digital marketing.
June 3, 2024 Anti-Semitism Letter Sent to MIT President Kornbluth and MIT Cor...Levi Shapiro
Letter from the Congress of the United States regarding Anti-Semitism sent June 3rd to MIT President Sally Kornbluth, MIT Corp Chair, Mark Gorenberg
Dear Dr. Kornbluth and Mr. Gorenberg,
The US House of Representatives is deeply concerned by ongoing and pervasive acts of antisemitic
harassment and intimidation at the Massachusetts Institute of Technology (MIT). Failing to act decisively to ensure a safe learning environment for all students would be a grave dereliction of your responsibilities as President of MIT and Chair of the MIT Corporation.
This Congress will not stand idly by and allow an environment hostile to Jewish students to persist. The House believes that your institution is in violation of Title VI of the Civil Rights Act, and the inability or
unwillingness to rectify this violation through action requires accountability.
Postsecondary education is a unique opportunity for students to learn and have their ideas and beliefs challenged. However, universities receiving hundreds of millions of federal funds annually have denied
students that opportunity and have been hijacked to become venues for the promotion of terrorism, antisemitic harassment and intimidation, unlawful encampments, and in some cases, assaults and riots.
The House of Representatives will not countenance the use of federal funds to indoctrinate students into hateful, antisemitic, anti-American supporters of terrorism. Investigations into campus antisemitism by the Committee on Education and the Workforce and the Committee on Ways and Means have been expanded into a Congress-wide probe across all relevant jurisdictions to address this national crisis. The undersigned Committees will conduct oversight into the use of federal funds at MIT and its learning environment under authorities granted to each Committee.
• The Committee on Education and the Workforce has been investigating your institution since December 7, 2023. The Committee has broad jurisdiction over postsecondary education, including its compliance with Title VI of the Civil Rights Act, campus safety concerns over disruptions to the learning environment, and the awarding of federal student aid under the Higher Education Act.
• The Committee on Oversight and Accountability is investigating the sources of funding and other support flowing to groups espousing pro-Hamas propaganda and engaged in antisemitic harassment and intimidation of students. The Committee on Oversight and Accountability is the principal oversight committee of the US House of Representatives and has broad authority to investigate “any matter” at “any time” under House Rule X.
• The Committee on Ways and Means has been investigating several universities since November 15, 2023, when the Committee held a hearing entitled From Ivory Towers to Dark Corners: Investigating the Nexus Between Antisemitism, Tax-Exempt Universities, and Terror Financing. The Committee followed the hearing with letters to those institutions on January 10, 202
Strategies for Effective Upskilling is a presentation by Chinwendu Peace in a Your Skill Boost Masterclass organisation by the Excellence Foundation for South Sudan on 08th and 09th June 2024 from 1 PM to 3 PM on each day.
Your Skill Boost Masterclass: Strategies for Effective Upskilling
Chapter 13Dissociative DisordersSteven Jay Lynn, Joanna M. Ber.docx
1. Chapter 13
Dissociative Disorders
Steven Jay Lynn, Joanna M. Berg, Scott O. Lilienfeld, Harald
Merckelbach, Timo Giesbrecht, Dalena Van-Heugten-Van Der
Kloet, Michelle Accardi-Ravid, Colleen Mundo, and Craig P.
Polizzi
The most recent edition of the Diagnostic and Statistical Manual
of Mental Disorders (DSM-5; American Psychiatric Association
[APA], 2013) defines dissociative disorders as conditions
marked by a disruption of and/or discontinuity in the normal
integration of consciousness, memory, identity, emotion,
perception, body representation, motor control, and behavior”
(p. 291). The presentation of dissociative disorders is often
dramatic, perplexing, and highly variable, both within and
across individuals. The hallmarks of dissociation are profound
and often unpredictable shifts in consciousness, the sense of
self, and perceptions of the environment.
DSM-5 asserts that the dissociative disorders share a common
feature: They are frequently manifested in the wake of trauma
and are influenced by their proximity to trauma (p. 291). Later
in the chapter, we contrast the post-traumatic theory that is
firmly embedded in the DSM-5 account of dissociation with a
competing theory that does not conceptualize trauma as a
necessary precursor to dissociation. In the course of our
discussion, we will present a case study that illustrates the
treatment of a patient with dissociative identity disorder (DID)
and highlight controversies that have dogged the field of
dissociation since the time of Janet's seminal writings on the
topic (Janet, 1889/1973).
The DSM-5 (APA, 2013) identifies three major dissociative
disorders that we discuss in turn—dissociative amnesia,
depersonalization/derealization, and DID. We then present an
overview of dissociation in general, followed by a more detailed
discussion of diagnostic considerations, prevalence, assessment,
2. and etiology specific to each of the dissociative disorders.
1. Dissociative amnesia is marked by an inability to recall
important autobiographical information, usually of a traumatic
or stressful nature inconsistent with ordinary forgetting. This
condition most often “consists of localized or selective amnesia
for a specific event or events, or generalized amnesia for
identity and life history” (APA, 2013, p. 298).
2. Depersonalization/derealization disorder (DDD), formerly
known as depersonalization disorder, is diagnosed on the basis
of symptoms of persistent depersonalization, derealization, or
both. Depersonalization symptoms include experiences of
unreality; feelings of detachment or being an outside observer
of one's thoughts, feelings, sensations, or actions; an unreal or
absent sense of self; physical and emotional numbing; and time
distortion. In contrast, derealization experiences involve
feelings of unreality or detachment with respect to one's
surroundings that include the experience of individuals or
objects as unreal, dreamlike, foggy, visually distorted, or
lifeless.
3. Dissociative identity disorder (DID; formerly called multiple
personality disorder) is marked by a disruption of identity
characterized by two or more distinct personality states and
recurrent gaps in the recall of everyday events, personal
information, and/or traumatic events that are inconsistent with
ordinary forgetting (APA, 2013, p. 292).
DSM-5 also includes a fourth category of other specified
dissociative disorder, for patients who do not meet full criteria
for any dissociative disorder. The essential features here are
chronic and recurrent clusters of mixed dissociative symptoms,
identity disturbance due to prolonged and intense coercive
persuasion, acute dissociative reactions to stressors, and
dissociative trance. Additionally, DSM-5 includes a fifth
category of unspecified dissociative disorder in which criteria
are not met for a specific dissociative disorder and there is
insufficient information to make a more specific diagnosis.
Finally, DSM-5 currently describes a dissociative subtype of
3. post-traumatic stress disorder (PTSD) in which persistent or
recurring feelings of depersonalization and/or derealization are
manifested in reaction to trauma-related stimuli. DSM-
5 requires that the symptoms of all dissociative disorders must
cause significant distress, impairment of functioning in major
aspects of daily life, or both, and must not be attributable to the
effects of a substance or another medical condition.
Some epidemiological studies among psychiatric inpatients and
outpatients have reported prevalence rates of dissociative
disorders exceeding 10% (Ross, Anderson, Fleischer, & Norton,
1991; Sar, Tutkun, Alyanak, Bakim, & Barai, 2000; Tutkun,
Sar, Yargiç, Özpulat, Yank, & Kiziltan, 1998), and a study
among community women in Turkey even reported a prevalence
rate of 18.3% for lifetime diagnoses of a dissociative disorder
(Sar, Akyüz, & Dogan, 2007). In contrast, many authors would
take issue with these high prevalence rates in both clinical and
nonclinical samples. Indeed, as our discussion will reveal,
estimates of the prevalence of dissociative disorders vary
widely and are surrounded by considerable controversy.
Although many authors regard symptoms of
depersonalization/derealization and dissociative amnesia as core
features of dissociation, the concept of dissociation is
semantically open and lacks a precise and generally accepted
definition (Giesbrecht, Lynn, Lilienfeld, & Merckelbach, 2008).
This definitional ambiguity is related, in no small measure, to
the substantial diversity of experiences that fall under the rubric
of “dissociation.” Dissociative symptoms range in their
manifestation from common cognitive failures (e.g., lapses in
attention), to nonpathological absorption and daydreaming, to
more pathological manifestations of dissociation, as represented
by the dissociative disorders (Holmes et al., 2005).
This variability raises the possibility that some of these
symptoms are milder manifestations of the same etiology or
have different etiologies and biological substrates, raising
questions about whether dissociation is a unitary conceptual
domain (Hacking, 1995; Holmes et al., 2005; Jureidini, 2003).
4. Indeed, van der Hart, Nijenhuis, Steele, and Brown (2004, 2006)
have distinguished ostensibly trauma-related or pathological
dissociation, which they term structural dissociation of the
personality, from nonpathological dissociative experiences
(e.g., altered sense of time, absorption). Structural dissociation,
in turn, can be subdivided into levels that encompass primary
dissociation, which is thought to involve one purportedly
apparently normal part of the personality (ANP) and one
emotional part of the personality (EP), secondary structural
dissociation, supposedly associated with a single ANP and
further division of the EP, and tertiary dissociation, ostensibly
limited to DID and characterized by several ANPs and EPs.
Nevertheless, as our review will demonstrate, researchers'
attempts to discriminate pathological from nonpathological
dissociative experiences psychometrically have been subject to
criticism and have been less than uniformly successful
(Giesbrecht et al., 2008; Modestin & Erni, 2004; Waller,
Putnam, & Carlson, 1996; Waller & Ross, 1997).
Other researchers (Allen, 2001; Cardeña, 1994; Holmes et al.,
2005) have proposed two distinct forms of dissociation:
detachment and compartmentalization. Detachment consists of
depersonalization and derealization, which we describe in some
detail later, and related phenomena, like out-of-body
experiences. Psychopathological conditions, which reflect
symptoms of detachment, include depersonalization disorder
and feelings of detachment that occur during flashbacks in
PTSD. Compartmentalization, in contrast, ostensibly
encompasses dissociative amnesia, marked by extensive
forgetting of autobiographical material, and somatoform
dissociation, such as sensory loss and “unexplained”
neurological symptoms (Nijenhuis, Spinhoven, Van Dyck, Van
der Hart, & Vanderlinden, 1998). The core feature of
compartmentalization is a deficit in deliberate control of
processes or actions that would normally be amenable to
control, as is evident in DID or somatization disorder. Although
clinicians may find it helpful to subdivide dissociative
5. symptoms into two different symptom clusters (Bernstein-
Carlson & Putnam, 1993), attempts to differentiate such clusters
on a psychometric basis have not been consistently successful
(see, for an example, Ruiz et al., 2008).
Dissociation is often presumed to reflect a splitting of
consciousness, although it must be distinguished from the
superficially similar but much debated concept of Freudian
repression. Specifically, dissociation can be described as a
“horizontal” split; that is, consciousness is split into two or
more parts that operate in parallel. In contrast, repression is
more akin to a “vertical” split, in which consciousness is
arranged in levels, and traumatic or otherwise undesirable
memories are ostensibly pushed downwards and rendered more
or less inaccessible.
Although the existence of dissociation as a clinical symptom is
not much in dispute, dissociative disorders are among the most
controversial psychiatric diagnoses. Disagreement generally
centers on the etiology of these disorders, with advocates often
arguing for largely trauma-based origins (e.g., Dalenberg et al.,
2012; 2014; Gleaves, 1996). In this light, dissociative symptoms
are regarded as manifestations of a coping mechanism that
serves to mitigate the impact of highly aversive or traumatic
events (Gershuny & Thayer, 1999; Nijenhuis, van der Hart, &
Steel, 2010). In contrast, skeptics often emphasize the role of
social influences, including cultural expectancies and
inadvertent therapist cueing of symptoms (e.g., Lilienfeld et al.,
1999; Lynn et al., 2015; McHugh, 2008). As we will learn later
in the chapter, the controversies stemming from etiology and
classification of dissociative disorders extend to their
assessment and treatment. We will focus our discussion on
chronic dissociative symptoms, rather than dissociation at the
time of a highly aversive event (i.e., peritraumatic dissociation).
Also, we will not elaborate on the dissociative subtype of PTSD
described in DSM-5 (see, for a critical analysis, Dutra & Wolf,
2017). However, we will present a number of “state” measures
of dissociation because researchers not infrequently consider
6. temporary changes in dissociation in the context of research on
more chronic presentations of dissociation.
Dissociative Amnesia
The diagnosis of dissociative amnesia requires that the memory
loss is extensive and not attributable to substance use or to a
neurological or other medical condition such as age-related
cognitive loss, complex partial seizures, or closed-head brain
injury and that the symptoms are not better explained by DID,
PTSD, acute stress disorder, somatic symptom disorder, or
major or mild neurocognitive disorder (APA, 2013, p. 298).
This disorder, formerly referred to as psychogenic amnesia,
often presents as retrospective amnesia for some period or
series of periods in a person's life, frequently involving a
traumatic experience.
DSM-5 lists several subtypes of dissociative amnesia. In
localized amnesia, the individual cannot recall any information
from a specific period of time, such as total forgetting of a
holiday week. Selective amnesia involves the loss of memories
for some, but not all, events from a specific period of time. In
generalized amnesia, individuals cannot recall anything about
their entire lives, and in continuous amnesia, individuals forget
each new event as it occurs. Finally, systematized amnesia
consists of the “loss of memory for specific categories of
information” (e.g., sexual abuse, a particular person). These last
three types of dissociative amnesia—generalized, continuous,
and systematized—are much less common than the others, and
may be manifestations of more complex dissociative disorders,
such as DID rather than dissociative amnesia alone.
Lynn et al. (2014a) argued that the central diagnostic criterion
for dissociative amnesia is vague and subjective in stipulating
that one or more episodes of inability to recall important
information must be “…inconsistent with ordinary forgetting”
(APA, 2013, p. 298). The reliability of judgments of what
constitutes “ordinary forgetfulness” is questionable, and what is
“ordinary” hinges on a variety of factors, including the
situational context and presence of comorbid conditions. A
7. similar point was raised by Read and Lindsay (2000), who
demonstrated that when people are encouraged to remember
more about a selected target event, they report their forgetting
to be more extensive, compared with individuals who are asked
to simply reminisce about a target event.
Epidemiology
Because rates of reporting vary so widely, it is difficult to
obtain reliable epidemiological information regarding
dissociative amnesia. Questions concerning the validity of
dissociative amnesia as a diagnostic entity are fueled by
markedly different prevalence rates in the general population
across cultures: 0.2% in China, 0.9% and 7.3% in Turkey, and
3.0% in Canada (Dell, 2009). These varying prevalence
estimates could reflect genuine cultural differences, but they
could just as plausibly reflect different interviewer criteria for
evaluating amnesia.
The DSM-5 states that dissociative amnesia can present in any
age group, although it is more difficult to diagnose in younger
children due to their difficulty in answering questions about
periods of forgetting and possible confusion with a number of
other disorders and conditions, including inattention, anxiety,
oppositional behavior, and learning disorders. There may be just
one episode of amnesia, or there may be multiple episodes, with
each episode lasting anywhere from minutes to decades. Other
sources (e.g., Coons, 1998) suggest that most cases occur in
individuals in their 30s or 40s, and that 75% of cases last
between 24 hours and 5 days. The prevalence of dissociative
amnesia is approximately equal between genders. Still others
argue that the scientific evidence for the existence of
dissociative amnesia is unconvincing, and that barring brain
injury or substance abuse or dependence, individuals who have
experienced trauma do not forget those events (e.g., McNally,
2003; Pope, Hudson, Bodkin, & Oliva, 1998).
Certain cases of purported traumatic amnesia are in fact
attributable to organic or other nondissociative causes. For
example, when critiquing a “convincing demonstration of
8. dissociative amnesia” (Brown, Scheflin, & Hammond, 1997),
McNally (2004) discussed a study (Dollinger, 1985) of two
children who witnessed a playmate struck and killed by
lightning, and who were later diagnosed with dissociative
amnesia. Yet as McNally noted, this diagnosis was clearly
mistaken, because the children had also been struck by lightning
and knocked unconscious.
Amusingly, and perhaps tellingly, Pope, Poliakoff, Parker,
Boynes, and Hudson (2007) offered a reward of $1,000 to “the
first individual who could find a case of dissociative amnesia
for a traumatic event in any fictional or nonfictional work
before 1800” (p. 225) on the basis that, whereas the vast
majority of psychological symptoms can be found in literature
or records dating back centuries, dissociative amnesia appears
only in more modern literature beginning in the late 1800s.
Over 100 individuals came forward with examples, but none met
the diagnostic criteria for the disorder (although the prize later
went to someone who discovered a case of dissociative amnesia
in a 1786 opera, Nina, by the French composer Nicholas
Dalayrac). Although Pope and colleagues' challenge does not
“prove” anything regarding the validity of the disorder, its
relative scarcity, and apparently recent (perhaps after the late
18th century) development, raise troubling questions about its
existence as a natural category or entity.
A special form of dissociative amnesia is crime-related amnesia.
Many perpetrators of violent crimes claim to experience great
difficulty remembering the essential details of the crime they
committed (Moskowitz, 2004). Memory loss for crime has been
reported in 25–40% of homicide cases and severe sex offenses.
Nevertheless, skeptics believe that genuine dissociative amnesia
in these cases is rare. They have pointed out that trauma victims
(e.g., concentration camp survivors) almost never report
dissociative amnesia (Merckelbach, Dekkers, Wessel, & Roefs,
2003). For example, Rivard, Dietz, Matell, and Widawski
(2002) examined a large sample of police officers involved in
critical shooting incidents and found no reports of amnesia.
9. Also, recent laboratory research shows that when participants
encode information while in a “survival mode,” this
manipulation yields superior memory effects (Nairne &
Pandeirada, 2008). This finding is difficult to reconcile with the
idea of dissociative amnesia while committing a crime. Thus, it
is likely that feigning underlies most claims of crime-related
amnesia (Van Oorsouw & Merckelbach, 2010), and the recent
literature provides detailed case studies illustrating this point
(Marcopolus, Hedjar, & Arredondo, 2016).
Dissociative Fugue
Dissociative fugue (previously called psychogenic fugue) is
arguably the most controversial dissociative phenomenon after
DID. In DSM-IV-TR, dissociative fugue (i.e., short-lived
reversible amnesia for personal identity, involving unplanned
travel or wandering) was listed as a separate diagnosis. In DSM-
5, dissociative fugue—defined therein as apparently purposeful
travel or bewildered wandering associated with amnesia
for identity or other important autobiographical information—is
no longer diagnosed as a disorder in its own right, but is instead
coded as a condition that can accompany dissociative amnesia.
In a fugue (“fugue” has the same etymology as the word
“fugitive”) episode, amnesia for identity may be so extreme that
a person physically escapes his or her present surroundings and
adopts an entirely new identity. If and when this identity
develops, it is often characterized by higher levels of
extraversion than the individual displayed pre-fugue, and he or
she usually presents as well integrated and nondisordered.
Periods of fugue vary considerably across individuals, both in
duration and in distance traveled. In some cases, the travel can
be a brief and relatively short trip, whereas, in more extreme
cases, it can involve traveling thousands of miles and even
crossing national borders. While in the dissociative fugue state,
individuals often appear to be devoid of psychopathology; if
they attract attention at all, it is usually because of amnesia or
confusion about personal identity. Again, it is doubtful that
fugues constitute a fixed and cross-cultural diagnostic category.
10. Hacking (1995) provides a detailed historical and critical
analysis of fugue showing that they first appeared in the 19th
century and since that time fluctuated in apparent prevalence
and acceptance by the psychiatric community.
Diagnostic Considerations
Although DSM-5 notes that dissociative fugue, with travel, is
not uncommon in DID, dissociative fugue may manifest with
other symptoms, including depression, anxiety, dysphoria, grief,
shame, guilt, stress, and aggressive or suicidal impulses (APA,
2013). Reportedly, the condition often develops as a result of
traumatic or stressful events, which has led to controversy and
ambiguity regarding the relation between dissociative fugue and
PTSD. Precipitants associated with the development of
dissociative fugue include war or natural disasters, as well as
the avoidance of various stressors, such as marital discord or
financial or legal problems (Coons, 1998). Such avoidance
suggests that clinicians must be certain to rule out malingering
and factitious disorders before diagnosing dissociative fugue.
Staniliou and Markowitsch (2014) discuss basic memory
mechanisms that might be involved in fugue states.
Certain culture-bound syndromes exhibit similar symptoms to
dissociative fugue. These include amok, present in Western
Pacific cultures (which has given rise to the colloquialism
“running amok”), pibloktok, which is present in native cultures
of the Arctic, and Navajo “frenzy” witchcraft, all of which are
marked by “a sudden onset of a high level of activity, a
trancelike state, potentially dangerous behavior in the form of
running or fleeing, and ensuing exhaustion, sleep, and amnesia”
for the duration of the episode (APA, 2000, p. 524; Simons &
Hughes, 1985).
Epidemiology
DSM-IV-TR places the population prevalence estimate of
dissociative fugue at 0.02%, with the majority of cases
occurring in adults (APA, 2000, p. 524). Ross (2009b) observed
that in the approximately 3,000 individuals he treated in his
trauma program over a 12-year period, he encountered fewer
11. than 10 individuals with pure dissociative amnesia or pure
dissociative fugue, although he noted that symptoms of amnesia
and fugue were common in the patients he admitted.
Depersonalization/Derealization Disorder
Depersonalization/derealization disorder (DDD) is one of the
most common dissociative disorders and perhaps the least
controversial. In DDD, reality testing remains intact (APA,
2013, p. 302): Individuals are aware that the sensations are not
real and that they are not experiencing a break from reality akin
to psychosis. In a departure from DSM-IV, in which
depersonalization and derealization were diagnosed
separately, DSM-5 created a new diagnostic category of DDD.
This “lumping” of formerly separate conditions is supported by
findings (Simeon, 2009a) that individuals with derealization
symptoms do not differ significantly from those with
depersonalization accompanied by derealization in salient
respects (e.g., illness characteristics, comorbidity,
demographics).
Greatly contributing to our knowledge about depersonalization
symptoms has been the development of well-validated screening
instruments, notably the Cambridge Depersonalization Scale
(CDS; Sierra & Berrios, 2000; Sierra, Baker, Medford, & David,
2005). Depersonalization episodes are not uncommonly
triggered by intense stress and are often associated with high
levels of interpersonal impairment (Simeon et al., 1997).
Episodes of depersonalization or derealization are also
frequently associated with panic attacks, unfamiliar
environments, perceived threatening social interactions, the
ingestion of hallucinogens, depression, and PTSD (Simeon,
Knutelska, Nelson, & Guralnik, 2003). Individuals with DDD
are also more likely than healthy individuals to report a history
of emotional abuse. In contrast, general dissociation scores are
better predicted by a history of combined emotional and sexual
abuse (Simeon, Guralnik, Schmeidler, Sirof, & Knutelska,
2001).
Diagnostic Considerations
12. Nearly 50% of adults have experienced at least one episode of
depersonalization in their lifetimes, usually in adolescence,
although a single episode is not sufficient to meet criteria for
the disorder (Aderibigbe, Bloch, & Walker, 2001). Because
depersonalization and derealization are common, DDD should
be diagnosed only if these symptoms are persistent or recurrent
and are severe enough to cause distress or impairment in
functioning, or both. The distress associated with DDD may be
extreme, with sufferers reporting they feel robotic, unreal, and
“unalive.” They may fear becoming psychotic, losing control,
and suffering permanent brain damage (Simeon, 2009a).
Individuals with DDD may perceive an alteration in the size or
shape of objects around them. Other people may appear
mechanical or unfamiliar, and affected individuals may
experience a disturbance in their sense of time (Simeon &
Abugel, 2006).
Although symptoms of depersonalization often occur in the
presence of psychotic symptoms (e.g., Gonzalez-Torres et al.,
2010; Goren et al., 2012; Vogel, Braungardt, Grabe, Schneider,
& Klauer, 2013), a diagnosis of DDD requires that the
symptoms do not occur exclusively in the course of another
mental disorder, nor can they be attributable to substance abuse
or dependence or to a general medical condition. Furthermore,
DDD should not be diagnosed solely in the context of
meditative or trance practices.
Symptoms of other disorders, such as anxiety disorders, major
depression, somatoform disorders, substance use disorders, and
certain personality disorders (especially avoidant, borderline,
and obsessive-compulsive), may also be present in the context
of DDD (Belli, Ural, Vardar, Yesilyrt, & Oncu, 2012; Lynn et
al., 2014b; Simeon et al., 1997). Depersonalization and
derealization symptoms are also commonly part of the symptom
picture of acute stress disorder (ASD; APA, 2013), which is
often a precursor to PTSD.
Epidemiology
DSM-5 estimates the lifetime prevalence of DDD in the United
13. States at 2%, with a range of 0.8– 2.8% (see also Ross, 1991),
suggesting that DDD might be as common as or more common
than schizophrenia and bipolar disorder. DDD is diagnosed
almost equally in women and men (Simeon et al., 2003). It
frequently presents for treatment in adolescence or adulthood,
even as late as the 40s, though its onset may be earlier.
Estimates of the age of onset of DDD range from 16.1 (Simeon
et al., 1997) to 22 years (Baker et al., 2003).
The onset and course of DDD vary widely across individuals.
Some people experience a sudden onset and others a more
gradual onset; some experience a chronic form of the disorder,
whereas others experience it episodically. In about two-thirds of
people with DDD, the course is chronic, and symptoms of
depersonalization are present most of the time, if not
continually. Episodes of depersonalization may last from hours
to weeks or months, and in more extreme cases, years or
decades (Simeon, 2009a).
Dissociative Identity Disorder
According to DSM-5, “the defining feature of DID is the
presence of two or more distinct personality states or
experiences of possession” (APA, 2013, p. 292). Thus, the
requirement that people diagnosed with DID must experience
distinct identities that recurrently take control over one's
behavior is no longer present. Importantly, in DSM-5 “distinct
personality states” replaces the term identities. The diagnostic
language in DSM-5 represents a marked departure from DSM-
II (APA, 1968), which used the term multiple personalities, and
from DSM-IV (APA, 1994), which labeled the condition DID to
underscore alterations in identity, rather than fixed and/or
complete “personalities.”
These shifts in diagnostic criteria may prove to be problematic
and result in changes in the prevalence rates of DID. For
example, what constitutes a personality state or an experience
of possession may be open to greater interpretation compared
with previous iterations of DSM. Moreover, in DSM-5, signs
and symptoms of personality alteration may be not merely
14. “observed by others,” but also “reported by the individual”
(APA, 2013; p. 292), further expanding opportunities for the
diagnosis of DID. In cases in which alternate personality states
are not witnessed, in DSM-5 it is still possible to diagnose the
disorder when there are “sudden alterations or discontinuities in
sense of self or agency…and recurrent dissociative amnesias”
(APA, 2013; p. 293), creating even more latitude and
subjectivity in the diagnosis of DID. Moreover, amnesia is no
longer restricted to traumatic events and may now be diagnosed
in relation to everyday events, which may also increase the base
rates of diagnosed DID. Although DSM-5 no longer defines DID
in terms of “distinct identities that recurrently take control of
the individual's behavior” (DSM-IV, p. 519), in the remainder
of the chapter, we will not refrain from using the
terms personalities and identities, insofar as these terms (a)
continue to be widely used in the extant literature and (b)
encompass “personality states.”
Diagnostic Considerations
To meet diagnostic criteria for DID, an individual's symptoms
cannot be attributable to substance use or to a medical
condition, and the “disturbance is not a normal part of a broadly
accepted cultural or religious practice” (APA, 2013; p. 292).
When the disorder is assessed in children, the symptoms must
not be confused with imaginary play. To recognize cultural
variants of dissociative phenomena, DSM-5 refers to a
“possession form” of DID, which is “typically manifest as
behaviors that appear as if a ‘spirit,’ supernatural being, or
outside person has taken control, such that the individual begins
speaking or acting in a distinctly different manner” (APA, 2013,
p. 293). Because such manifestations are not uncommon in
different cultures (see, for a discussion of trance/possession
phenomena, Cardeña, van Duijl, Weiner, & Terhune, 2009), to
warrant a diagnosis of DID, the identities must be present
recurrently, be unwanted or …
11 Feeding, Eating and Elimination Disorders
15. The diagnostic criteria for the Feeding and Eating Disorders in
this chapter are categorized by recurrent disordered eating
activities and attitudes that are mutually exclusive, with the
exception of pica, which results in significant physical and/or
psychosocial impairment (APA, 2013). Research demonstrates
that eating disorders often originate in childhood or adolescence
with the average age of onset between 8 and 21 years (Hudson,
Hiripi, Pope, & Kessler, 2007). Approximately 20 million
women and 10 million men in the United States suffer from a
clinically significant eating disorder during their lifetime
(Wade, Keski-Rahkonen, & Hudson, 2011). Despite this
prevalence, only one in ten individuals with an eating disorder
receives treatment (Noordenbox, 2002). It is estimated that over
90% of those diagnosed with an eating disorder are young
females between the ages of 12 and 25 (SAMHSA, 2003), but
adult males suffer significantly as well (EDC, 2007).
Data from the National Comorbidity Replication Survey
(NCS-R) and the Adolescent Supplement (NCS-A) show that
adults and children with eating disorders often have coexisting
mental disorders such as depression, anxiety, and substance use;
sadly, few seek treatment specific to their eating disorder. More
distressing, this data demonstrates that eating disorders are
often associated with functional impairment and suicidality
(Hudson et al., 2007; Swanson, Crow, Le Grange, Swendsen &
Merikangas, 2011).
The first three disorders were relocated to this category
“Feeding and Eating Disorders” to highlight that although they
are most often diagnosed in children, they can occur at any age,
including adulthood. These disorders are distinguished by
problems with the process of eating and retaining food, eating
inappropriate food, or lack of interest in or avoidance of food.
Among individuals with intellectual disabilities their presence
appears to increase with the severity of the condition. Pica
Disorder is the eating of nonfood items such as paint chips,
string, hair, or newspaper. Although it may occur with other
eating and mental disorders, symptoms must be severe enough
16. to warrant an independent diagnosis. Rumination Disorder
involves vomiting and re-eating food. Avoidant/Restrictive
Food Intake Disorder was formerly feeding disorder of infancy
or early childhood, but it has been expanded to capture a
broader range of symptoms and age levels. This disruption in
eating and feeding behavior is marked by continuous inability to
meet appropriate sustenance and dietary needs. It is associated
with a serious decrease in body weight, failure to grow,
nutritional deterioration, reliance on enteral feeding and
impairment in psychosocial functioning (APA, 2013). For any
of these diagnoses, all three eating disorders should not develop
solely during the course of another eating disorder and cannot
be a culturally sanctioned practice or attributable to a medical
condition or another mental disorder (See DSM-5 for full
description of these disorders.)
The following three eating disorders are considered very
serious due to their chronic nature and morbidity, especially
without treatment. The first, Anorexia Nervosa, has an annual
prevalence rate of “0.4% among young females, with a 10:1
female-to-male ratio” (APA, 2013, p. 341) and is characterized
by significant weight loss resulting from excessive dieting and a
distorted body image. “Significantly low weight is defined as a
weight that is less than minimally normal or, for children and
adolescents, less than minimally expected” (APA, 2013, p. 338).
Individuals affected by this disorder have an unreasonable fear
of becoming fat regardless of their low body weight, which
interferes with weight gain. This intense focus on being thin is
often accompanied by a distorted body image; that is, the
individuals experience their weight or shape as greater than
what it actually is and often lack insight into the gravity of their
low body composition (APA, 2013).
There are two subtypes of Anorexia Nervosa: Restricting
Type and Binge/ Purging Type. Subtypes are used to identify
current symptoms over the last 3 months and often alternate
between subtypes. Individuals with the Restricting Type
severely restrict their food intake without engaging in bingeing
17. or purging behaviors. Individuals with the Binge/Purging Type
of anorexia maintain their weight at an abnormally low level
through food restriction but also engage in binge eating and
purging behaviors, such as self-induced vomiting or laxative or
diuretic abuse. Clinicians need to specify if individuals are in
partial (some of the criteria are met) or full (no criteria are met)
remission if the client previously met the full criteria. Also, the
current severity level of clinical symptoms and functioning
needs to be indicated from mild to extreme based on body mass
index (BMI) for adults and percentiles for children and
adolescents (APA, 2013).
Another significant eating disorder, Bulimia Nervosa (BN) is
also more prevalent in young females, “estimated at 1% to
1.5%” with female-to-male ratios similar to anorexia (APA,
2013, p. 347). Individuals suffering from bulimia generally
maintain a normal weight for their age and height. The primary
issue for the individual diagnosed with bulimia is a pattern of
binge eating that occurs at least once per week for 3 months.
This is followed by contradictory actions to avoid weight gain,
such as vomiting; laxative, diuretic, or enema abuse; fasting; or
excessive exercise. Additionally, bulimia is accompanied by
both a loss of control and excessive concern related to body
shape/weight. A binge consists of eating a larger amount of
food than normal under similar circumstances in a relatively
short period of time (usually less than 2 hours). To meet
diagnostic criteria, the bulimic behavior must not occur entirely
during episodes of anorexia nervosa. Clinicians need to specify
whether in partial or full remission as well as severity level
based on frequency of episodes of inappropriate compensatory
behaviors, from mild to extreme (APA, 2013).
Binge Eating Disorder (BED) became a diagnostic category in
the DSM-5 and is defined as repeating episodes of excessive
eating accompanied by feeling a loss of restraint and marked
distress. To meet diagnostic criteria, 3 out of 5 of the following
features must be present: eating more quickly than is typical;
eating without the physical sensation of hunger; eating until
18. excruciatingly full; eating alone out of shame over amount
consumed; and, feeling hopeless, remorse, and depressed
afterward. For diagnosis, frequency of bingeing episodes must
be at least once per week for 3 months and cannot arise only
during the course of anorexia or bulimia. Diagnosis must
specify the current severity of binge episodes (from mild to
extreme) as well as remission status (partial/full) if applicable
(APA, 2013).
Although BED is the most common eating disorder there is
limited knowledge about its development. Annual prevalence
“among U.S. adult (age 18 or older) females and males is 1.6%
and .08%, respectively” (APA, 2013 p. 351) to lifetime
prevalence rates of 3.5% in women and 2.0% in men (Hudson et
al., 2007). Gender differences are closest in BED than in either
anorexia or bulimia, with development still more prevalent in
women. However, for subthreshold BED, this gender ratio
reverses with males 3 times higher than females (Hudson et al.,
2007). BED has been shown to occur across the developmental
lifespan with age of onset generally reported as adolescence but
occurrence in adulthood is not uncommon (APA, 2013).
Eating Disorders Not Otherwise Specified (EDNOS) has been
replaced with two categories. The first, Other Specified Feeding
or Eating Disorder, applies to demonstrations that do not meet
the full criteria for any of the eating disorders in this section. It
is used when the “clinician chooses to communicate the specific
reason that the presentation does not meet the criteria for any
specific feeding and eating disorder” (APA, 2013, p. 353),
which must be included in diagnosis (for examples see DSM-5).
The other category, Unspecified Feeding or Eating Disorder, is
used to signal that there is inadequate information available for
the clinician to make a more specific diagnosis, such as in an
emergency room setting (APA, 2013).
Assessment
In assessing a client with a potential eating disorder, it is
important to conduct a thorough psychosocial evaluation,
including demographic information, reason for visit (which may
19. be different from the principal diagnosis), support systems,
family information, medical history, and any other history of
mental health intervention (see Chapter 1).
Clients who present with eating-disordered symptomatology
may not initially feel comfortable discussing behaviors
associated with the disorder due to the stigma, shame, and fear
of being discovered. Often, the behaviors have been held secret
for a significant period of time. The clients may be afraid of
family and friends pressuring them to change the behavior
before they are ready to make any changes.
Even when the eating-disordered person appears confident,
accomplished, fearless, and intelligent, the internal experience
is painful (e.g., terror of “getting caught,” pervasive feelings of
confusion or turmoil, concern about “going crazy”). Although it
may be obvious that the client has an eating disorder, several
sessions may be required before the client is willing to
acknowledge the problem. Family members may even maintain
or support such denial because eating-disordered behaviors
(e.g., dieting, overeating, abstaining from eating,
overexercising) are learned from the previous generation.
Although a client may be able to talk about the eating
disorder, the client or his or her family may question the
validity of such a diagnosis. For example, the parents of an
anorectic girl might suggest that their daughter just wants to
look like all the models in the magazines. In order for the
practitioner to address this defensive stance, it is crucial to join
with the family and establish good rapport and communication;
a nonjudgmental and empathic attitude; and a calm, neutral,
matter-of-fact tone concerning the eating-disordered symptoms.
If the clinician infuses the assessment interview with too much
emotion, the client and family may intensify their guardedness
and withdraw from treatment.
Adolescents with eating disorders are often pressured into
therapy by their parents, school counselors, friends, or relatives.
Their resistance to therapy may require the practitioner to focus
on other nonfood- or weight-related issues for a considerable
20. length of time before the adolescents develop enough trust to
confide in the therapist. Adults with eating disorders may be
motivated to come into therapy for a variety of reasons other
than wanting to recover from the eating disorder. Such reasons
may include wanting to assuage the family's or friends' worries;
fear of a particular medical manifestation, such as bleeding,
tachycardia, or incontinence; or problems with interpersonal
relationships.
Assessment of an individual who the practitioner suspects
might have an eating disorder involves exploring several
specific areas that pertain to eating behaviors and attitudes.
First, the practitioner should obtain a history of dieting or
compulsive eating habits. Second, the client should be assessed
for present symptoms of specific eating-disordered patterns
(e.g., restricting food intake, vomiting, abusing laxatives,
hiding food, hoarding food, having strict lists of “safe” foods,
being obsessed with recipes and cooking, and engaging in
excessive exercise routines).
Often these behaviors are accompanied by symptoms of
depression, low self-esteem, distorted body image,
hopelessness, anxiety, and, in more severe cases, suicidal
tendencies. Due to the possibility of comorbidity, specific
assessments can be conducted to rule out concurrent mental
disorders such as substance abuse, major depression, body
dysmorphic disorder, and obsessive-compulsive disorder. In
addition, personality disorders such as borderline personality
disorder, dependent personality disorder, histrionic personality
disorder, and avoidant personality disorder should be
considered.
People with eating disorders tend to have very rigid, fixed
thought patterns. This may affect their social relationships,
interpersonal skills, and ability to maintain intimate connections
with other people (e.g., close friends, partners, close work
relationships, family ties). If the client is under 18 years old,
the family situation should be thoroughly assessed. Family
factors that have been found to contribute to anorectic behavior
21. in adolescence include enmeshed family systems, blurred
boundaries between parents and children, and lack of separation
and individuation. Family factors that may influence bulimic
and compulsive overeating behaviors include chaotic family
dynamics, power imbalances, lack of flexibility, and a lack of
clear family structure. In all types of eating disorders, factors
that characterize families could potentially include a history of
sexual abuse or traumatic events, squelching of emotional
expression, and power and control issues.
Finally, it is essential that the eating-disordered client's case
be followed by a medical doctor while the client is in therapy
for the eating disorder. Clients with anorexia who fall below a
minimum weight are often hospitalized because of the life-
threatening risks that emaciation poses. Bulimic clients can
develop electrolyte imbalances and other physical problems that
can lead to medical complications. It is often necessary to have
a written contract with eating-disordered clients stating that if
they fall below a certain minimum weight, they understand that
they will be hospitalized. In addition, the practitioner must
obtain written consent from clients to exchange information
with the physician.
Assessment Instruments
The Eating Disorder Examination (EDE; Cooper & Fairburn,
1987; Fairburn & Cooper, 1993) is a well-validated and widely
used instrument to diagnose eating disorders (Cooper, Cooper,
& Fairburn, 1989; Grilo et al., 2010; Rizvi, Peterson, Crow, &
Agras, 2000. Peterson, Crow, & Agras, 2000). This
semistructured interview in its 16th edition, takes
approximately 1 hour to administer and assesses anorexia
nervosa, bulimia nervosa and binge eating disorder based on
responses to 33 open-ended questions (both Likert and
dichotomous). Training in both the technique of the interview as
well as the instrument is required.
The EDE is composed of 4 subscales related to the cognitive
symptomatology of eating disorders that measure dietary
restraint as well as eating, weight, and shape concern. Also,
22. behavioral symptoms are assessed including frequency of binge
eating, self-induced vomiting, laxative/diuretic misuse, and
excessive exercise. Scoring for these subscales is on a 7-point
scale (0–6) with higher scores indicating greater frequency or
severity of symptoms. For most items a 28-day timeframe is
employed, except for diagnostic purposes when a longer time
period may be required. A symptom composite score can be
calculated by averaging the diagnostic items. Research indicates
good internal consistency (Cooper et al., 1989) and inter-rater
reliability and test–retest reliability (Reas, Grilo & Masheb,
2004) over 2 to 7days for all the EDE subscales and high inter-
rater reliability (Rizvi et al., 2000). Good inter-rater reliability
and test–retest reliability for the EDE (6 to 14 days) was shown
in adult patients with BED (Reas et al., 2004). Research by
Berg, Peterson, Frazier, and Crow (2012) demonstrates that the
EDE scores correlate with measures of similar constructs and
support the use of this instrument to distinguish between eating
disorder cases and controls; however, they point out that no
studies to date have assessed the inter-rater reliability of scores
on items that assess laxative/diuretic misuse or excessive
exercise. There is a child's version (ChEDE) of this scale
designed specifically for use with children ages 8 to 14 (Bryant-
Waugh, Cooper, Taylor, & Lask, 1996) as well as a self-report
questionnaire (EDE-Q) that have been shown to correlate with
the EDE.
The Eating Disorder Inventory-3 (EDI-3; Garner, 2004) is a
self-report questionnaire used to assess the symptoms and
presence of eating disorders in individuals aged 13 and above.
This is the third version of one of the most popular self-report
scales (EDI; Garner, Olmsted, & Polivy, 1983 & EDI-2, Garner,
1991), and it consists of 91 items (same as EDI-2) that are rated
on a 6-point scale from “always” to “never.” It is organized into
12 scales (e.g., drive for thinness, bulimia, body dissatisfaction)
and yields 6 composite scores, including eating disorder risk
and 5 common psychological constructs. Higher scores indicate
a greater likelihood of an eating disorder. Furthermore, this
23. version included individuals with an EDNOS diagnosis, which
covers binge eating. The EDI-3 demonstrates good
discriminative validity and good to adequate internal
consistency (Garner, 2004; Cumella, 2006) with recent studies
of women demonstrating results that were even better than the
original (Clausen, Rosenvinge, Friborg, & Rokkedal, 2011).
The Eating Disorder Diagnostic Scale (EDDS; Stice, Telch, &
Rizvi, 2000) is a brief, 22-item, self-report screening measure
of anorexia nervosa (AN), bulimia nervosa (BN), and binge
eating (BE) disorders. The items can be standardized for
consistency and averaged (with the exception of 2 items) to
provide a symptom composite score, and the scale can be
administered in less than 10 minutes. Psychometric studies
provided criterion, convergent, and predictive validity of the
EDDS with samples containing adolescents and adults, as well
as nonclinical and clinical populations. The eating disorder
symptom composite demonstrated internal consistency (.89) and
convergent validity with similar scales assessing eating
pathology (EDE and SCID-I). The 1-week test–retest
coefficients were .95 (AN), .71 (BN), and .75 (BED) (Stice et
al., 2000; Stice, Fisher, & Martinez, 2004). Krabbenborg et al.
(2011); established an overall symptom composite cutoff score
of 16.5, which accurately distinguished those with a disorder
from controls and may be useful in identifying subthreshold
patients as well as detecting possible protective intervention
effects. Later factor analysis found good internal consistency
related to four factors of the scale: body dissatisfaction,
bingeing behaviors, bingeing frequency, and compensatory
behaviors (Lee et al., 2007).
The Eating Attitudes Test (EAT-26; Garner, Olmsted, Bohr, &
Garfinkel, 1982) is a brief, self-report screening measure of
eating disorder symptoms and is not intended to make a
diagnosis. Many studies have been conducted using the EAT-26
as a screening tool, including the 1998 National Eating Disorder
Screening Program (NEDSP). This 26-item questionnaire
contains 3 subscales: dieting (13 items), bulimia and food
24. preoccupations (6 items), and oral control (7 items).
Respondents must rate whether each item applies on a 6-point
scale (e.g., “always,” “usually,” “often,” “sometimes,” “rarely,”
or “never”). Items are summed to produce a total score. Clients
who score above 20 are considered at risk for an eating disorder
and referred for a diagnostic interview. Additionally,
information is gathered on the individual's BMI, and five
behavioral questions ask about weight-control behaviors (e.g.,
binge, vomit, laxative/diuretic, exercise, and weight loss). The
EAT-26 is easy to administer and score and has good
psychometrics (Mintz & O'Halloran, 2000).
The EAT-26 does not yield a specific diagnosis of an eating
disorder. A disorder must have a prevalence approaching 20% in
order for the test to be efficient in detection. This instrument
was developed and validated on primarily female populations
and is most often used to assess female high school and college
students. The EAT-26 can be useful in measuring pathology in
underweight girls but also shows a high false-positive rate in
distinguishing eating disorders from disturbed eating behaviors
in college women.
The EAT-26 has a children's version (ChEAT-26; Maloney,
McGuire, & Daniels, 1988) for use with children aged 8–13
years with psychometric properties similar to the adult version
(alpha = .88 with low item 19 deleted) and a suggestion that this
measure be further modified if used with younger children since
alphas increased with each grade level. The standard cutoff
score of 20, which is used with adults, was recommended
(Smolak & Levine, 1994; Sancho, Asorey, Arija, & Canals,
2005). Lack of honesty or accuracy in self-reporting can limit
the usefulness of the EAT-26, particularly with anorexia.
However, the EAT-26 has been shown to be useful in detecting
cases of anorexia nervosa, and the assessor can then combine
information gained from this assessment and other assessment
procedures to make a diagnosis (Maloney et al., 1988).
Emergency Considerations
Eating disorders are among the most lethal psychiatric illnesses
25. in the DSM-5 (APA, 2013). Meta-analysis conducted by
Arcelus, Mitchell, Wales, and Nielsen (2011), found that
mortality rates are substantial among individuals with eating
disorders, especially in those with anorexia nervosa. The
weighted annual mortality rates were 5 per 1000 person-years
for anorexia nervosa (AN), 1.7 per 1000 person-years for
bulimia nervosa (BN), and 3 per 1000 person-years for EDNOS.
More striking, one in 5 individuals with AN who died had
committed suicide. Additionally, age at assessment was found to
be a significant predictor of mortality for individuals with
anorexia. Utilizing data from the National Comorbidity Survey
Replication Adolescent Supplement, Swanson et al. (2011)
found that most adolescents who had a diagnosis of AN, BN,
and BED in the past 12 months reported significant role
impairment (97%, 78%, and 63%, respectively) especially in
their social and family relationships. Moreover, suicide risk was
demonstrated for all eating disorders. Bulimia and subclinical
anorexia were correlated with suicide plans, and BN and BED
were linked with suicide attempts.
Due to the physical complications that can develop from
starvation, laxative abuse, diuretic abuse, and vomiting
behaviors, clients with eating disorders can develop life-
threatening medical conditions that require emergency medical
procedures. Therefore, the practitioner who is working with
eating-disordered clients must develop a “team” approach to
treatment and include a physician or nurse practitioner, a
dentist, a nutritionist, and other medical professionals on the
treatment team to effectively treat the client.
Clients with eating disorders also often suffer from severe
depressive episodes that may lead to feelings of hopelessness
and, ultimately, suicidal behaviors. If the practitioner assesses
the client to have depressive symptoms, the severity of the
depression along with suicidal ideation should be considered.
Crisis intervention strategies should be utilized and a
psychiatric evaluation conducted if necessary to stabilize the
client and keep him or her safe.
26. Cultural Considerations
Culture beliefs and attitudes are factors that influence the
development of eating disorders (Miller & Pumariega, 2001). It
is important to recognize that in the developed Western
European and North American countries, food is taken for
granted, and only in countries in which there is an abundance of
food do eating disorders flourish. Poor and underdeveloped
countries in which food is scarce have far fewer eating-
disordered individuals among their populations. Cultural values,
therefore, are an important aspect of this illness. Culture shapes
both attitudes and behaviors related to body image and eating,
especially when values about physical aesthetics are involved.
For example, some cultural risk factors for anorexia include
social pressure to be thin (e.g., media attention/peer pressure)
and the focus on body image (Polivy & Herman, 2002; Striegel-
Moore & Bulik, 2007). Western culture's emphasis on thin
idealization can contribute to eating disorders, but it is not
solely culpable. Although the underlying causes of eating
disorders are not entirely clear, a multifactorial relationship that
includes biological, psychological, and sociocultural factors is
most accepted.
There is a growing controversy over why the number of
minorities with eating disorders is relatively low. Many feel
that the research on eating disorders in women of color suffers
from both underreporting and researcher bias (NEDA, 2012),
both of which can result in minorities going undiagnosed. Some
studies show that the experiences of African-American and
Caucasian female adolescents are extremely different, with
African-American girls being proud of their bodies regardless
of the cultural pressure to be thin (Woodrow Wilson
International Center for Scholars, 2000). A cultural identity that
embraces larger body types than does the dominant culture may
account for why some African-American women are at a lower
risk than White American females for developing eating
disorders that focus on thinness. This suggests that a protective
effect may exist in terms of ethnicity and culture for black
27. American females against the development of some eating
related psychopathology. However, Asian women reported equal
to higher levels of eating dysfunction as white American women
(Wildes, Emery, & Simons, 2001). In contrast, research on
Latinas showed that they are more inclined to exhibit binge
eating rather than restricting behaviors (Smolak & Striegel-
Moore, 2001). Significant ethnic differences emerged for
bulimia, with Hispanic adolescents reporting the highest
prevalence; there was a trend toward ethnic minorities reporting
more binge eating, while non-Hispanic White adolescents
tended to report more anorexia (Swanson et al., 2011).
However, for binge eating, other studies showed that risk
factors did not include ethnicity but rather childhood obesity
and familial eating problems in studies comparing Black and
White women (Striegel-Moore et al., 2005). The variability that
exists across studies is noteworthy and warrants further study.
Contrary to earlier beliefs, a growing number of studies
suggest that U.S. ethnic minority groups are trending toward
higher levels of eating disorders and that the relationship
between ethnicity and disordered eating may vary by disorder
(Striegel-Moore, 2000; Striegel-Moore & Smolak,
2000; Cachelin, Striegel-Moore, & Regan, 2006). One study, for
example, conducted in Minnesota among over 81,000
adolescents, found that the highest prevalence for disordered
eating was among Hispanic and Native American teens of both
genders (Croll, Neumark-Sztainer, Story, & Ireland, 2002).
Quite often this trend is attributed to acculturation (i.e., how
much they have adopted the values and behaviors of the
prevailing culture). As minorities accept the dominant culture's
values, they are subjected to the same kinds of pressures to be
thin as their Caucasian counterparts. Findings by Davis and
Katzman (1999) showed that in Chinese university students
increased acculturation was associated with greater reports of
bulimia and drive for thinness in females and greater
perfectionism in males, both factors in distorted eating.
Measuring the prevalence of eating disorders in minority
28. populations is further complicated by the fact that they are
underrepresented in most studies, and the likelihood that they
will seek help/ treatment or be asked about eating disorder
symptoms is poor (Stein, 2000). The role that ethnicity plays in
the development of distorted eating needs to be further studied
(Boisvert & Harrell, 2012; White & Grilo, 2005; Striegel-Moore
et al., 2005).
Eating disorders (ED) occur more frequently in women;
however, men are less likely to be diagnosed as they are often
stereotyped as female disorders (SAMHSA, 2011). Adolescent
studies regarding lifetime prevalence estimates found no sex
differences in the prevalence of anorexia or subclinical binge
eating disorders, while for bulimia, binge eating disorder and
subclinical anorexia prevalence was higher in girls (Swanson et
al., 2011). Just as was observed in minorities, eating disorders
are increasing among males as they are finding themselves
subjected to the same cultural ideals in regards to body image
and social pressures that women face (Boisvert & Harrell,
2012). For example, 10% to 15% of individuals with anorexia
and bulimia are male, and among gay men, the numbers …
Title
ABC/123 Version X
1
Feeding and Eating and Sleep–Wake Disorders Worksheet
CCMH/548 Version 5
1
University of Phoenix Material
Feeding and Eating and Sleep–Wake Disorders Worksheet
Choose three feeding and eating disorders, and three sleep–
wake disorders.