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- 1. EEaattiinngg DDiissoorrddeerrss LeighFalls Holman, PhD, LPC-S, RPTS, NCC
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- 3. SSccrreeeenniinngg aanndd AAsssseessssmmeenntt Screening should occur with any individual indicating issues with body weight, body shape, or attitudes towards eating that appear to be disordered Suicidality should be assessed at the same time due to elevated risk in individuals with eating disorders Depression and anxiety symptoms should be assessed
- 4. SSCCOOFFFF SSccrreeeenn Doyou make yourself Sick because you feel uncomfortably full? Do you worry you have lost Control over how much you eat? Have you recently lost more than One stone in a 3 month period? Do you believe yourself to be Fat when others say you are too thin? Would you say that Food dominates your life? *One point for every ‘yes’ **Score of ≥ 2 indicates a likely case of anorexia or bulimia Morgan, J. Reid, F. , (1999). The SCOFF questionnaire: Assessment of a new screening tool for eating disorders. British Medical Journal. 319:1467. doi: http://dx.doi.org/10.1136/bmj.319.7223.1467 http://en.wikipedia.org/wiki/SCOFF_questionnaire
- 5. AACCOORRNN EEaattiinngg DDiissoorrddeerrIInnvveennttoorryy http://foodaddictioninstitute.org/Publications/
- 6. EEaattiinngg AAttttiittuuddeess TTeesstt http://psychcentral.com/quizzes/eat.htm 40 item version – EAT-40 (Garner & Garfinkel, 1979) 26 item version - EAT-26 (Garner, Olmsted, Bohr, & Garfinkel, 1982) 12 item version – EAT-12 (Lavik, Clausen, & Pedersen, 1991). Children’s Eating Attitudes Test (ChEAT; Maloney et al., 1989) Sensitivity .77; specificity .95 & .94; Positive predictive values .82 & .79; negative predictive values .93 & .94 3 factors (across cultures and gender and age): ◦ Dieting and purging behaviors ◦ Binging and food preoccupation ◦ Social pressures to eat
- 7. Eating Attitudes Test((GGaarrnneerr && GGaarrffiinnkkeell,, 11997799)) EEAATT--2266 SSeellff TTeesstt 26 Item self-report inventory: http://eat-26.com/Form/ 40 item EAT-40 http://eat-26.com/Form/index.php?test_type=Good concurrent validity (Williamson, Anderson, Jackman, & Jackson, 1995). Simple and Quick May be given repeatedly to gauge progress in treatment
- 8. Bulimia TTeesstt--RReevviisseedd ((BBUULLIITT--RR)) ((TThheelleenn,, FFaarrmmeerr,, WWoonnddeerrlliicchh,, && SSmmiitthh,, 11999911)) 28 item questionnaire based on DSM II-R R = .99 Can discriminate BN from AN Cutoff – 104 Brief, easy to score, well-validated ◦ Internal Consistency: (Adult women: r = .92-.98; Girls: r = .9; Boys: r = .88) ◦ Test-Retest over 2 month period: .95 ◦ High concurrent and convergent validity in adult and adolescent females Screening or progress in treatment
- 9. Eating DDiissoorrddeerr EExxaammiinnaattiioonn((EEDDEE)) CCooooppeerr && FFaaiirrbbuurrnn,, 11998877;; FFaaiirrbbuurrnn && CCooooppeerr,, 11999933)) 2 behavioral indices ◦ Overeating ◦ Methods of extreme weight control 4 Subscales: ◦ Restraint ◦ Eating concern ◦ Shape concern ◦ Weight concern Investigator-based interview Inter-rater reliability (Cooper, Fairburn, 1987; Wilson & Smith, 1989); Test-Retest (Rizvi, Peterson, Crow, & Agras, 2000); & Internal consistency (Cooper, Cooper, & Fairburn, 1989). Commonly used in treatment outcome studies Requires training to use
- 10. Interview for theDiagnosis ooff EEaattiinngg DDiissoorrddeerrss--IIVV ((IIDDEEDD--IIVV)) ((KKuuttlleessiicc,, WWiilllliiaammssoonn,, GGlleeaavveess,, BBaarrbbiinn,, && MMuurrpphhyy--EEbbeerreennzz,, 11999988)) Semi-structured interview Differential Diagnosis DSM-IV AN, BN, & BED Good reliability and validity (Kutlesic et al., 1998) Strength: client responses are rated on severity scales directly related to DSM-IV criteria Score of 3 or above on a 1-5 scale is diagnostic Following interview, rater completes a diagnostic checklist using the severity ratings that leads directly to differential diagnosis according to DSM-IV criteria.
- 11. EEaattiinngg DDiissoorrddeerr IInnvveennttoorryy--33 ((GGaarrnneerr,, 11999911)) Self-report inventory Assess symptoms of AN and BN Provides standardized assessment of severity of symptoms – not diagnostic Can provide useful background info Validated with both clinical and non-clinical groups across different cultures, both adolescents and adults Translated into Arabic, Bulgarian, Chinese, Dutch, German, Hebrew, Portuguese, Spanish, & Swedish Moderate to high internal consistency (r = .70-.93) for subscales 91 questions, 11 subscales ◦ 3 assess attitudes and behaviors concerning eating, weight, and shape ◦ Other 8 assess: psychological disorders, Ineffectiveness, perfectionism, interpersonal distrust, introspective Awareness, Maturity Fears, Ascetics, Impulse Regulation, and Social Insecurity
- 12. FFiigguurree 99..22:: MMeeddiiccaallEEffffeeccttss ooff AAnnoorreexxiiaa
- 13. FFiigguurree 99..33:: DDiiaaggnnoossttiiccCCrroossssoovveerr iinn EEaattiinngg DDiissoorrddeerrss
- 14. DDiiaaggnnoossiiss DSM 5Chapter: Feeding and Eating Disorders Clinical Features: ◦ “persistent disturbance of eating or eating-related behavior that results in the altered consumption or absorption of food and that significantly impairs physical health or psychosocial functioning” (APA, p. 329)
- 15. SSiimmiillaarriittiieess ttoo SSuubbssttaanncceeAAddddiiccttiioonnss:: “Some individuals with disorders described in this chapter report eating-related symptoms resembling those typically endorsed by individuals with substance use disorders, such as craving and patterns of compulsive use” (APA, p. 329). “This resemblance may reflect the involvement of the same neural systems, including those implicated in regulatory self-control and reward, in both groups of disorders. However, the relative contributions of shared and distinct factors remain insufficiently understood” (APA, p. 329).
- 16. AAnnoorreexxiiaa NNeerrvvoossaa ((330077..11)) ((CCrriitteerriioonn AA)) Restriction of energy intake relative to requirements, leading to a significantly low body weight in the context of age, sex, developmental trajectory, and physical health. Significantly low weight is defined as a weight that is less than minimally normal or, for children and adolescents, less than that minimally expected. If you weight the client in the office, then make certain shoes are off, overcoats/sweaters are off, and pockets are emptied prior to weighing.
- 17. AAnnoorreexxiiaa NNeerrvvoossaa ((CCrriitteerriioonnBB)) Diagnostic Features: ◦ Persistent energy intake restriction ◦ Intense fear of gaining weight or of becoming fat, or persistent behavior that interferes with weight gain ◦ Disturbance in self-perceived weight or shape
- 18. AAnnoorreexxiiaa NNeerrvvoossaa ((CCrriitteerriioonnCC)) Disturbance in the way in which one’s body weight or shape is experienced, undue influence of body weight or shape on self-evaluation, or persistent lack of recognition of the seriousness of the current low body weight.
- 19. AAnnoorreexxiiaa NNeerrvvoossaa ((CCooddiinngg)) Regardless of code, specify which type. Crossover between subtypes over the course of the disorder is not uncommon. Therefore, subtype describes current symptoms only. The ICD-9 Code is 307.1 which is assigned regardless of the subtype. The ICD-10 CM code depends on the subtype: ◦ Restricting Type (F50.01): During the last 3 months the individual has not engaged in recurrent episodes of binge eating or purging behavior (i.e. self-induced vomiting or misuse of laxatives, diuretics or enemas). ◦ Binge-Eating/Purging Type (F50.02): During the last 3 months, the individual has engaged in recurrent episodes of binge eating or purging behavior (i.e. self-induced vomiting or misuse of laxatives, diuretics or enemas).
- 20. AAnnoorreexxiiaa NNeerrvvoossaa ((SSppeecciiffiieerrss)) Remission, if applicable: After full criteria previously met, ◦ Partial Remission: Criterion A (low body weight) has not been met for a sustained period, but either Criterion B (intense fear of gaining weight or becoming fat or behavior that interferes with weight gain) or Criterion C (disturbances in self-perception of weight and shape) is still met. ◦ Full Remission: None of the criteria have been met for a sustained period of time. Current Severity: (adults – based on BMI and children and adolescents based on BMI percentile). Severity may be increased to reflect clinical symptoms, the degree of functional disability, and the need for supervision. ◦ Mild: BMI ≥ 17 kg/m2 ◦ Moderate: BMI 16-16.99 Kg/m2 ◦ Severe: BMI 15-15.99 kg/m2 ◦ Extreme: BMI ≤ 15 kg/m2
- 21. AAnnoorreexxiiaa NNeerrvvoossaa:: AAssssoocciiaatteeddFFeeaattuurreess Some health effects may be reversed with nutritional rehabilitation, but some are not completely reversible, such as bone mineral density Comorbidity: ◦ Depression – Suicide risk is elevated (12/100,000/year) ◦ Biploar Disorder ◦ Anxiety Disorders ◦ Obsessive Compulsive features (both related and unrelated to food – restricting type more likely to have OCD) ◦ Substance Addictions (more common with binge/purge type) ◦ Hoarding Semi-starvation may be associated with: ◦ Problems with major organs (heart) ◦ Physiological disturbance (amenorrhea) ◦ Vital sign abnormalities ◦ May or may not have lab abnormalities
- 22. AAnnoorreexxiiaa NNeerrvvoossaa More females than males 10:1 12 month prevalence for females is approximately .4% Usually begins during adolescence or young adulthood, but rarely before puberty or after 40 ◦ Younger: may manifest atypical features, including denying ‘fear of fat.’ ◦ Older: more likely to have a longer duration of the illness & clinical presentation may include more signs and symptoms of long-standing disorder Course and outcome are highly variable ◦ Course: Onset often triggered by stressful life event ◦ Outcomes: Some individuals recover fully after a single episode of AN. However, some have fluctuating or chronic problems with AN over their lives. Hospitalization may be required to restore weight and to address medical complications. Remission rates lower for these folks. Most experience remission within 5 years of presentation (p. 342) Mortality rate 5% per decade due most often to medical complications or suicide.
- 23. AAnnoorreexxiiaa NNeerrvvoossaa:: RRiisskk&& PPrrooggnnoossttiicc FFaaccttoorrss Temperamental: ◦ “individuals who develop anxiety disorders or display obsessional traits in childhood are at an increased risk of developing AN Environmental: ◦ “Historical and cross-cultural variability in the prevalence of AN supports its association with cultures and settings in which thinness is valued” (APA, p. 342). ◦ “Avocations that encourage thinness, such as modeling and elite athletics, are also associated with increased risk. (APA, p. 342). Genetic and Physiological: ◦ Increase risk in 1st degree biological relatives ◦ Increased risk of bipolar and depressive disorders of 1st degree relatives, particularly binge/purge type ◦ Monozygotic twins higher than dizygotic twins ◦ Brain abnormalities using fMRI identified (but this may result from malnutrition vs. primary abnormalities)
- 24. AAnnoorreexxiiaa NNeerrvvoossaa:: DDiiaaggnnoossttiiccMMaarrkkeerrss Hematology Serum Chemistry Endocrine Electrocardiography Bone Mass Electroencephalography Resting Energy Expenditure Physical Signs and Symptoms
- 25. AAnnoorreexxiiaa NNeerrvvoossaa:: FFuunnccttiioonnaallCCoonnsseeqquueenncceess May function socially and professionally or may not Social isolation Failure to fulfill academic or career potential
- 26. AAnnoorreexxiiaa NNeerrvvoossaa:: DDiiffffeerreennttiiaallDDiiaaggnnoossiiss Medical Conditions such as gastrointestinal disease, hyperthyroidism, occult malignancies, and AIDS. Major Depressive Disorder Schizophrenia Substance Use Disorders Social Anxiety Disorder (Social phobia), OCD, and Body Dysmorphic Disorder Bulimia Nervosa Avoidant/restrictive Food Intake Disorder *What is the primary cause of the symptom?
- 27. BBuulliimmiiaa NNeerrvvoossaa ((330077..5511,,FF5500..22)) CCrriitteerriioonn AA Recurrent episodes of binge eating. An episode of binge eating is characterized by both of the following: 1. Eating, in a discrete period of time (e.g., within any 2-hour period), an amount of food that is definitely larger than what most individuals would eat in a similar period of time under similar circumstances. 2. A sense of lack of control over eating during the episode (e.g., a feeling that one cannot stop eating or control what or how much one is eating).
- 28. BBuulliimmiiaa NNeerrvvoossaa BingingTriggers ◦ Interpersonal stressors ◦ Dietary restraint ◦ Negative feelings related to body weight, body shape, and food ◦ boredom Consequences ◦ Negative self-evaluation ◦ Dysphoria
- 29. BBuulliimmiiaa NNeerrvvoossaa ((CCrriitteerriiaa,,ccoonntt..)) B. Recurrent inappropriate compensatory behaviors in order to prevent weight gain, such as self-induced vomiting; misuse of laxatives, diuretics, or other medications; fasting; or excessive exercise. C. The binge eating and inappropriate compensatory behaviors both occur, on average, at least once a week for 3 months. D. Self-evaluation is unduly influenced by body shape and weight. E. The disturbance does not occur exclusively during episodes of anorexia nervosa.
- 30. BBuulliimmiiaa NNeerrvvoossaa ((SSppeecciiffiieerrss)) Remission: After full criteria for BN were previously met, ◦ In partial remission: Some, but not all, of the criteria have been met for a sustained period of time. ◦ In full remission: None of the criteria have been met for a sustained period of time. Severity (current): the minimum level of severity is based on the frequency of inappropriate compensatory behaviors. It may be increased to reflect other symptoms and the degree of functional disability. ◦ Mild: An average of 1-3 episodes per week of inappropriate compensatory behavior ◦ Moderate: An average of 4-7 episodes per week of inappropriate compensatory behavior ◦ Severe: An average of 8-13 episodes per week of inappropriate compensatory behavior ◦ Extreme: An average of 14 or more episodes per week of inappropriate compensatory behavior
- 31. BBuulliimmiiaa NNeerrvvoossaa:: DDiiaaggnnoossttiiccFFeeaattuurreess Recurrent episodes of binge eating Recurrent inappropriate compensatory behaviors to prevent weight gain Self-evaluation unduly influenced by body shape and weight Must occur 1x/week for 3 months on average
- 32. BBuulliimmiiaa NNeerrvvoossaa:: AAssssoocciiaatteeddFFeeaattuurreess Typically normal weight or overweight (BMI ≥ 18.5 and ≤ 30 in adults). Uncommon among obese individuals Between binges – restrict caloric intake Menstrual irregularity Fluid and electrolyte disturbances due to purging Rare but potentially fatal complications including esophageal tears, gastric rupture, and cardiac arrhythmias. Serious cardiac and skeletal myopathies may happen due to vomiting Abuse of laxatives may lead to dependence Gastrointestinal symptoms and rectal prolapse
- 33. BBuulliimmiiaa NNeerrvvoossaa Prevalence: ◦ 12 month prevalence among young females is 1%-1.5%. ◦ Prevalence is highest among young adults – peaks in older adolescence and young adulthood. ◦ More common in females than males 10:1. Course and Outcome: ◦ Onset before puberty or after 40 is uncommon. ◦ Frequently begins during or after an attempt at dieting. ◦ Multiple stressful life events can precede onset ◦ Disturbed eating behavior persists for at least several years in most clinical samples – may be chronic or intermittent ◦ Symptoms of many diminish over time without treatment, although treatment clearly impacts outcome ◦ Remission longer than 1 year associated with better outcome ◦ Significantly elevated risk for mortality (all-cause and suicide) Crude mortality rate – 2% per decade. ◦ Diagnostic cross-over to AN 10%-15% - often have multiple cross-overs between AN and BN ◦ May cross-over to BED
- 34. BBuulliimmiiaa NNeerrvvoossaa:: RRiisskk&& PPrrooggnnoossttiicc FFeeaattuurreess Temperamental: ◦ Weight concerns, low self-esteem, depressive symptoms, social anxiety disorder, and overanxious disorder of childhood are associated with increased risk for the development of BN. Environmental: ◦ Internalization of a thin body ideal increases risk. Childhood sexual/physical abuse are at an increased risk. Genetic and Physiological: ◦ Childhood obesity and early pubertal maturation increase risk. ◦ Familial transmission of BN may be present, as well as genetic vulnerabilities for BN Course Modifiers: ◦ Severity of psychiatric comorbidity predicts worse long-term outcome of BN
- 35. BBNN:: FFuunnccttiioonnaall CCoonnsseeqquueenncceess Severe role impairment Social-life domain most likely to be adversely affected Suicide risk elevated
- 36. BBNN:: DDiiffffeerreennttiiaall DDiiaaggnnoossiiss Anorexia Nervosa, Binge-eating/purging type Binge Eating Disorder Kleine-Levin Syndrome: disturbed eating does not include over-concern about body shape or weight Major Depressive Disorder, with Atypical Features Borderline Personality Disorder: impulsive behavior in BPD may result in BN symptoms
- 37. BBNN CCoommoorrbbiiddiittyy Mosthave one other mental health issue Many have multiple comorbidities Increased frequency of: ◦ Depressive symptoms, bipolar & depressive disorders ◦ Anxiety symptoms (social situations) or anxiety disorders ◦ Substance Use Disorders (30% lifetime prevalence among BN clients)
- 38. ((330077..5511//FF5500..88))BBiinnggee EEaattiinngg DDiissoorrddeerr DSM IV TR: ◦ Appendix B: Criteria Sets and Axes Provided for Further Study ◦ Diagnosed as ED NOS DSM 5: ◦ Added BED to Feeding and Eating Disorders chapter ◦ Recognition that a large percentage of ED NOS diagnoses could be attributed to BED ◦ More severe and less common than overeating and associated with significant physical and psychological problems ◦ Criteria A-E will must be met
- 39. Binge Eating DDiissoorrddeerr((CCrriitteerriioonn AA)) A. Recurrent episodes of binge eating. An episode of binge eating is characterized by both of the following: 1.Eating, in a discrete period of time (w/in 2-hour period), an amount of food that is definitely larger than what most people would eat in a similar period of time under similar circumstances. 2.A sense of lack of control over eating during the episode (e.g. feeling that one cannot stop eating or control what or how much one is eating).
- 40. Binge EEaattiinngg DDiissoorrddeerr((CCrriitteerriioonn BB)) B. The binge-eating episodes are associated with 3/more of the following: 1. Eating much more rapidly than normal. 2. Eating until feeling uncomfortably full. 3. Eating large amounts of food when not feeling physically hungry. 4. Eating alone because of feeling embarrassed by how much one is eating. 5. Feeling disgusted with oneself, depressed or very guilty afterward.
- 41. Binge Eating DDiissoorrddeerr((CCrriitteerriiaa,, CCoonntt..)) C. Marked distress regarding binge eating is present. D. The binge eating occurs, on average, at least once a week for 3 months. E. The binge eating is not associated with the recurrent use of inappropriate compensatory behavior as in bulimia nervosa and does not occur exclusively during the course of bulimia nervosa or anorexia nervosa.
- 42. Binge Eating DisorderSSppeecciiffiieerrss ((pp.. 335500)) Partial/Full Remission After full criteria for BED were met, binge-eating disorder were previously met, ◦Partial: Binge eating occurs at an average frequency of less than one episode per week for a sustained period of time. ◦Full: none of the criteria have been met for a sustained period of time. Severity ◦Mild: 1-3 episodes of binge eating each week ◦Moderate: 4-7 episodes of binge eating each week ◦Severe: 8-13 episodes of binge eating each week ◦Extreme: 14/more episodes of binge eating each week
- 43. BBEEDD:: AAssssoocciiaatteedd FFeeaattuurreess Prevalence: (p. 351) ◦ 12 month prevalence among adults: Female: 1.6% Males: .8% Development & Course : (p. 352) ◦ Binge eating usually precedes BED whereas dieting usually precedes onset of binge eating in bulimia nervosa) ◦ Treatment seeking BED clients are usually older than AN/BN treatment seeking clients ◦ Course: persistent, similar to BN in severity & duration Risk and Prognostic Factors: Indication of Genetic predisposition
- 44. BBEEDD:: AAssssoocciiaatteedd FFeeaattuurreess Culture-Related Diagnostic Issues ◦ Similar across industrialized countries ◦ Similar across ethnicities Functional Consequences ◦ Social role adjustment problems ◦ Impaired health-related quality of life & life satisfaction ◦ Increased medical morbidity & mortality ◦ Increased health care utilization compared with BMI-matched control subjects
- 45. BBEEDD:: AAssssoocciiaatteedd FFeeaattuurreess Differential Diagnosis ◦ Bulimia Nervosa: BED doesn’t have recurrent compensatory (purge/exercise) behavior BED consistently higher rates of improvement than BN ◦ Obesity: BED higher rates of overvaluation of body weight and shape BED rates of psychiatric comorbidity are significantly higher BED better outcomes ◦ Bipolar & MDD can be given in addition to BED if meet full criteria for both ◦ Borderline PD & BED can be given if meet full criteria for both Comorbidity *linked to severity of BED not degree of obesity* ◦ Most common: bipolar, depressive, & anxiety disorders ◦ Less common: substance use disorders
- 46. OOtthheerr SSppeecciiffiieedd FFeeeeddiinnggoorr EEaattiinngg DDiissoorrddeerr ((330077..5599 Atypical AN: all criteria met, except that despite significant weight loss, the individual’s weight is within or above normal limits. Bulimia Nervosa (of low frequency and/or limited duration) Binge-Eating Disorder (of low frequency and/or limited duration Purging Disorder
- 47. TTrreeaattmmeenntt Eating Disordersrequires specific interventions Training and supervised practice under the supervision of an eating disorders specialist is necessary for competency in this area. Must be able to work on an inter-disciplinary treatment team due to the medical and nutritional issues related to these disorders.
- 48. RReessoouurrcceess aavvaaiillaabbllee oonnlliinnee Eating Disorders Warning Signs http://achancetoheal.org/eating-disorders/warning-signs/ Differential Diagnosis Tree Fast Facts about EDs http://www.aedweb.org/About_Eating_Disorders/3645.htm Eating Disorders Parent Toolkit Feelings Wheel Guide to Medical Management of Eating Disorders Meal Support Manual for Parents/Friends Parent’s Role in Prevention Bulimia Nervosa Guide
- 49. RReessoouurrcceess EatingDisorders Factsheet APA: http://www.dsm5.org/Documents/Eating%20Disorders%20Fact%20Sheet.pdf Eating Disorders Helpline: http://www.anad.org/eating-disorders-get-help/eating-disorders-helpline-email/ Eating Disorder Support Groups by State: http://www.anad.org/eating-disorders-get-help/eating-disorders-support-groups/ Support Groups: http://www.allianceforeatingdisorders.com/Support-Groups Eating Disorders Anonymous: http://www.eatingdisordersanonymous.org/ EDA Meetings: http://www.eatingdisordersanonymous.org/meetings.html Mentor Connect: Online mentoring relationships to replace eating disorders: http://www.mentorconnect-ed.org/
- 50. RReessoouurrcceess EatingDisorder Statistics: http://www.anad.org/get-information/about-eating-disorders/eating-disorders-statistics/ Eating Disorder Mortality Statistics: http://www.anad.org/get-information/about-eating-disorders/making-sense-of-ed-mortality-statistics/ Eating Disorders and Pro Eating Disorder Internet Sites: http://www.anad.org/get-information/eating-disorders-and-the-internet/ Righting Insurance Discrimination of Eating Disorders: http://www.anad.org/get-information/insurance-issues/ ECRI Institute for Research on Eating Disorder: https://www.ecri.org/Pages/default.aspx National Eating Disorders Association http://www.nationaleatingdisorders.org/
- 51. RReessoouurrcceess BingeEating Disorder Association: http://bedaonline.com/ Academy for Eating Disorders: http://www.aedweb.org//AM/Template.cfm?Section=Home The Eating Disorder Foundation: http://www.eatingdisorderfoundation.org/ The Alliance for Eating Disorders Awareness: DSM V Diagnostic Criteria http://www.allianceforeatingdisorders.com/dsm-bed Males and Eating Disorders: http://www.allianceforeatingdisorders.com/males-and-eating-disorders National Association for Males with Eating Disorders, Inc. http://www.namedinc.org/
- 52. RReessoouurrcceess SomethingFishy: Issues for Men with Eating Disorders: http://www.something-fishy.org/cultural/issuesformen.php Etiology of Eating Disorders http://www.allianceforeatingdisorders.com/what-causes-eating-disorders Suggested Reading on Eating Disorders: http://www.allianceforeatingdisorders.com/help-resources-suggested-readings Eating Disorders Organizations and Websites: http://www.allianceforeatingdisorders.com/organizations-and-websites About Face: http://www.about-face.org/ The Body Positive: http://www.thebodypositive.org/ Body Image Health: http://bodyimagehealth.org/
- 53. RReessoouurrcceess BecomingYour Most Authentic Self: http://bi3d.tridelta.org/Home Andrea’s Voice Foundation: Disordered Eating and Related Issues: http://andreasvoice.org/ The Elisa Project: Overcoming Eating Disorders Through Knowledge: http://www.theelisaproject.org/ Families Empowered And Supporting Treatment of Eating Disorders (FEAST): http://www.feast-ed.org/ Community Outreach Prevention of Eating Disorders: http://www.dahliapartnership.org/ Eating Disorders Coalition: http://www.eatingdisorderscoalition.org/ Eating Disorders Hope: http://www.eatingdisorderhope.com/
Editor's Notes
- #15 “persistent disturbance of eating or eating-related behavior that results in the altered consumption or absorption of food and that significantly impairs physical health or psychosocial functioning” (APA, p. 329)
- #16 “Some individuals with disorders described in this chapter report eating-related symptoms resembling those typically endorsed by individuals with substance use disorders, such as craving and patterns of compulsive use” (APA, p. 329). “This resemblance may reflect the involvement of the same neural systems, including those implicated in regulatory self-control and reward, in both groups of disorders. However, the releative contributions of shared and distinct factors remain insufficiently understood” (APA, p. 329).
- #17 “Can be challenging because normal weight can vary by individuals, and different thresholds have been published defining thinness or underweight status” (APA, p. 340). Criterion A: Restriction of energy intake relative to requirements, leading to a significantly low body weight in the context of age, sex, developmental trajectory, and physical health. Significantly low weight is defined as a weight that is less than minimally normal or, for children and adolescents, less than that minimally expected. If you weight the client in the office, then make certain shoes are off, overcoats/sweaters are off, and pockets are emptied prior to weighing.
- #18 “This intense fear of becoming fat is usually not alleviated by weight loss. In fact, concern about weight gain may increase even as weight falls” (APA, p. 340). Some clients may not recognize or acknowledge fear of gaining weight. The clinician may infer this fear based on observation, collateral information/history, physical and lab findings, or course over time either indicating a fear of gaining weight. Diagnostic Features: Persistent energy intake restriction Intense fear of gaining weight or of becoming fat, or persistent behavior that interferes with weight gain Disturbance in self-perceived weight or shape
- #19 Some feel globally overweight Others realize they are thin but still concerned about specific body parts (i.e. hips/stomach) being too large “They may employ a variety of techniques to evaluate their body size or weight, including frequent weighting, obsessive measuring of body parts, and persistent use of a mirror to check for perceived areas of ‘fat’” (APA, p. 340). Self-esteem is highly dependent on their perceptions of body shape and weight. See “weight loss as an impressive achievement and sign of extraordinary self-discipline” and gain as “an unacceptable failure of self-control” (APA, p. 340). Often they don’t realize the medical effects of their malnourished state.
- #22 Clients may have “concerns about eating in public, feelings of ineffectiveness, a strong desire to control one’s environment, inflexible thinking, limited social spontaneity, and overly restrained emotional expression” (APA, p. 341). Binge-eating/purging type: “have higher rates of impulsivity and are more likely to abuse alcohol and other drugs” (APA, pg. 341). Excessive physical activity: may pre-date the onset of the disorder Misuse of medication is common.
- #25 Hematology: Leukopenia common – loss of all cell types but with apparent lymphocytosis. Mild anemia can occur, as well as thrombocytopnia and rarely bleeding problems. Serum Chemistry: Dehydration may be refledted by an elevated blood urea nitrogen level. Hypercholesterolemia is common. Heptic enzyme levels may be elevated. Hypomagnesaemia, hypozicemia, hypophosphatemia, and hypermylasemia are occasionally observed. Self-induced vomiting may lead to metabolic alkalosis (elevated serum bicarbonate), hypocloremia, and hypokalemia Laxative abuse may cause a mild metabolic acidosis. Endocrine: Serum thyroxine (T4) levels are usually in low-normal range. Triiodothyronine (T3) levels are decreased, while reverse T3 levels are elevated. Females have low serum estrogen levels, whereas males have low levels of serum testosterone. Electrocardiography: Sinus bradycardia is common, and rarely, arrhythmias are noted. Significant prolongation of the QTc interval is observed in some individuals. Bone Mass: Low bone mineral density, with specific areas of osteopenia or osteoporosis, is often seen. Risk of fracture is significantly higher. Electroencephalography: Diffuse abnormalities, reflecting a metabolic encephalopathy, may result from significant fluid and electroltye disturbances. Resting Energy Expenditure: Often a significant reduction in resting energy expenditure Physical Signs and Symptoms: Amenorrhea is common Emaciation Significant hypotension, hypothermia, and bradycardia Some individuals develop luago, a fine downy body hair (looks like a monkey’s hair). Some develop peripheral edema, especially during weight restoration or upon cessation of laxative and diuretic abuse. Rarely, petechia or ecchymoses, usually on the extremities, may indicate a bleeding diathesis. Some have yellowing skin associated with hypercaratenemia. Those who self-indicue vomiting may have hypertorphy of the salvary glands, particularly the parotid glands, as well as dental enamel erosion. Some have scars or calluses on the dorsal surface of the hand from repeated contact with the teeth while inducing vomiting.
- #28 Typical in same circumstances: Think about Thanksgiving vs. a regular meal Loss of Control: Some individuals describe a dissociative quality to binging May feel acute loss of control over binging or generalized loss of control over eating patterns May have abandoned efforts to control binging – still counts as loss of control May be able to stop binging if interrupted due to shame about binging and being ‘found out’
- #39 We will go review the specific criteria for Binge Eating Disorder on the following slides. Associated Features: (351) Normal and overweight and obese individuals Distinct from obesity. Most obese individuals do not engage in recurrent binge eating. “Obese individuals with BED consume more calories in lab studies of eating behavior and have greater functional impairment, lower quality of life, more subjective distress, and greater psychiatric comorbidity than obese individuals without BED” (p. 351).
- #40 Diagnostic Features (p. 351) “The context in which the eating occurs may affect the clinician’s estimation of whether the intake is excessive. For example, a quantity of food that might be regarded as excessive during a typical meal might be considered normal during a celebration or holiday meal.” Discrete Period of Time: usually less than 2 hours Single episode: may not be restricted to one setting (i.e. restaurant & home but not continual snacking on small amounts of food throughout the day.) Sense of lack of Control: ”inability to refrain from eating or to stop eating once started.” Dissociative quality during or following May be able to stop if someone enters the room unexpectedly May be described as acute loss of control or general pattern of uncontrolled eating Binges can be planned Or May have stopped trying to control eating
- #41 Diagnostic Features: “Binge eating seems to be characterized more by an abnormality in the amount of food consumed than by a craving for a specific nutrient” (p. 351). Typically ashamed of their eating problems Secrecy: Attempt to conceal their symptoms Triggers: Negative affect (emotion regulation) Interpersonal stressors Dietary restraint Negative feelings related to body weight, body shape, and food Boredom “Binge eating may be minimized or mitigate factors that precipitated the episode in the short-term” (it works initially) “but negative self-evaluation and dysphoria often are delayed consequences” (indicates a addictive/relapse cycle)
- #44 Prevalence: 12 month prevalence among 18yo/older: Female: 1.6% Males: .8% Less skewed in BED than bulimia nervosa As frequent among racial/ethnic minorities as white women More prevalent among those seeking weight-loss treatment than general population Development: not much known about development of BED Associated with increased body fat, weight gain, and increases in psychological symptoms Common in adolescent and college-age samples Loss of control eating or episodic binge eating may represent a prodromal phase of eating disorders for some individuals. Binge eating usually precedes BED whereas dieting usually precedes onset of binge eating in bulimia nervosa) Usually begins in adolescence or young adulthood, but can begin in later adulthood. Course: Remission rates in both natural course and treatment outcome studies are higher for binge-eating disorder than for bulimia nervosa or anorexia nervosa. Relatively persistent, course is comparable to BN in terms of severity and duration Crossover from BED to AN/BN is uncommon
- #45 Risk & Prognostic Factors: “BED appears to run in families, which may reflect additive genetic influences” (p. 352). Culture-Related Diagnostic Issues: Prevalence of BED similar across industrialized countries and among Latinos, Asians, Caucasians, and African Americans. Functional Consequences of BED: Associated with Social role adjustment problems Impaired health-related quality of life and life satisfaction Increased medical morbidity and mortality Associated increased health care utilization compared with BMI-matched control subjects May be associated with an increased risk for weight gain & devmt of obesity
- #46 Differential Diagnosis: Bulimia Nervosa: Clinical presentation & recurrent inappropriate compensatory behavior (e.g., purging, driven exercise) – not in BED BED may report dieting attempts, but “don’t show marked or sustained dietary restriction designed to influence body weight & shape between binge-eating episodes” (352) Response to treatment: BED consistently higher rates of improvement than BN Obesity: Associated with obesity but different. BED clients with obesity have higher rates of overvaluation of body weight and shape BED rates of psychiatric comorbidity are significantly higher BED better treatment outcomes than obesity without BED Bipolar & Depressive Disorders: Increased eating in the context of major depressive episode may/may not be associated with loss of control. If full criteria are met for MDD/Bipolar Disorder and BED, then they can both be given. Borderline PD: “If full criteria for both disorders are met, both diagnoses should be given” (353). Comorbidity: Most common are bipolar disorders, depressive disorders, anxiety disorders Less common substance use disorders “Psychiatric comorbidity is linked to the severity of binge eating and not to the degree of obesity” (353).