1st half Flashcards
● DSM-V Criteria for Anorexia
A. Restriction of energy intake leading to significantly low body weight in context of what is minimally expected for age, sex, developmental trajectory, and physical health. Significantly low weight is defined as weight that is less than minimally normal or expected
B. Intense fear of gaining weight or of becoming fat, or persistent behavior that interferes with weight gain (even though significantly low weight).
C. Disturbance in the way one’s body weight or shape is experienced, undue influence of body shape and weight on self-evaluation, or persistent lack of recognition of the seriousness of the current low body weight.
Specifiers
Specify whether:
● Restricting Type: During the last 3 months, the individual has not regularly engaged in recurring binge-eating or purging behavior (ie, self-induced vomiting or the misuse of laxatives, diuretics, or enemas). This type refers to weight loss accomplished primarily through dieting, fasting, & or excessive exercise.
● Binge-Eating/Purging Type: During the last 3 months, the individual has regularly engaged in recurrent episodes of binge-eating or purging behavior (ie, self-induced vomiting or the misuse of laxatives, diuretics, or enemas).
Specify if:
● In partial remission: After full criteria for anorexia nervosa was previously met, Criterion A is no longer met for a sustained period of time. Either Criterion B or C is met.
● In full remission: After full criteria for anorexia nervosa was previously met, none of the criteria has been met for a sustained period of time
Specify current severity:
● Minimum level is the BMI for adults, BMI percentile for child and adolescents
● CDC BMI percentile calculator; below the 5th percentile for age
Anorexia Types
● Binge-Eating/Purging Type:
○ Elevated personal & family histories of obesity
○ Higher rates of impulsive behaviors including stealing, drug abuse, self-harm, & mood lability, than individuals with the restricting type of anorexia nervosa
Prevalence
● In adolescents
○ Lifetime prevalence is about 3% of 13 to 18 year olds
○ Of “Severe” about 3%
● In children less prevalent (.1% between ages 8-11)
More often in females for both adolescents and children
Development and Course
○ Rarely begins before puberty or above 40
○ Onset usually associated with a stressful event
○ Course and outcome highly variable
■ Older individuals can have longer duration of illness
■ Some individuals with AN recover after one episode
■ Some individuals have fluctuating weight gain followed by relapse
■ Most individuals experience remission within 5 years of presentation
○ Crude mortality rate (CMR) = 5% increase per decade
Culture
● Anorexia Nervosa occurs across culturally and socially diverse populations
● Cross-cultural variation in its occurrence and presence
● Differences in symptoms
Comorbidity
● Inconsistent findings due to limited data
○ Mood disturbance
○ Suicide
○ OCD and/or OCD features
○ Personality disorders (borderline personality more common)
○ Anxiety
○ Substance use
Diagnostic Markers
● Hematology (bloodwork) ● Serum (neurotransmitters) Chemistry ● Endocrine (estrogen & testosterone) ● Electroencephalography ● Bone mass
Medical Effects
● Most physical symptoms are a side-effect of starvation
○ Physical signs and symptoms
○ Gaunt & emaciation
○ Pale due to anemia
○ Dermatological changes: dry skin, lanugo hair, thinning hair
○ Yellow skin due to defect with liver
○ Orthostatic hypertension: standup to fast get dizzy
○ Cardiovascular changes: low heart rate & low blood pressure
○ Gastrointestinal changes: high constipation
○ Endocrine changes: loss of 15% of normal weight = amenorrhea
○ Muscle-skeletal changes: decomposition of muscle
○ Electrolyte abnormalities: salt/ potassium levels
○ Bone abnormalities: osteoporosis
○ Hypersensitivity to cold
● Purging:
○ Enlargement of salivary glands
○ Erosion of dental enamel
○ Osteopenia – lower than normal bone density
Emotional/Cognitive Symptoms
Many mood & personality symptoms are also an effect of starvation ○ Irritability ○ Rapid mood changes ○ Flat affect ○ Indecisiveness (executive functioning is affected) ○ Decreased sexual interest & sleep Cognition ○ Impaired concentration & alertness ○ Distractible, apathetic, lethargic ○ Black and white thinking because of indecisiveness: Need for control ○ Extreme preoccupation with food ○ Rituals associated with eating
suicide risk
● Elevated suicide risk
● 12 per 100,000 a year that are accted for
● Comprehensive assessment for anorexia should include assessment of suicidal ideation, suicide attempts, or other self-injurious behavior
Treatment
ANOREXIA NERVOSA
● The treatment literature on anorexia nervosa is limited in comparison to other psychological disorders
○ Chambless & Ollendick’s (2001) Adolescents: No empirically supported treatment for adolescent anorexia nervosa
○ Chambless & Ollendick’s (2001) Adults: Limited, but promising support for cognitive-behavior therapy & family therapy
○ Wilson et al.(2007) Over the past 20 years, there were only 15 comparative trials that were completed & published
● Treatment research limited due to (Grange & Lock, 2005):
● High patient attrition rates; low prevalence rates; ambivalent patient attitudes; duration of treatment; medical complications that result from symptoms of the disorder
Family Based Treatment
● The rationale for family-focused treatments is based on the idea that families make accommodations in feeding their child that initially appear useful in combating anorexia, but these ultimately become maladaptive, disrupting both the development of the adolescent with anorexia, and perpetuating the behaviors that maintain the disorder (Lock, 2010)
● According to the National Institute for Clinical Excellence, family interventions for eating disorders should be offered to younger patients, but specifies that family therapy need NOT be in place of individual therapy
Family Based Treatment Maudsley Approach
● Views the adolescent as not in control of their behavior but instead the eating disorder controls the adolescent
○ Three phase model:
■ Phase 1: Weight Restoration
■ Phase 2: Returning control over eating to the adolescent
■ Phase 3: Establishing healthy adolescent identity
● In addition to the Maudsley Hospital in London, this family-based approach to treatment is implemented by programs in Columbia University and Mt. Sinai School of Medicine in New York.
● Outcomes using this approach suggest it is effective for adolescents in the short term with 80–90% of patients with good to excellent progress and that treatment effects are maintained at longer term follow-up (Eisler et al., 2007; Le Grange and Lock, 2005; Lock et al., 2006)
Cognitive Behavioral Therapy: Individual Treatment
● Cognitive Behavioral Therapy (CBT) is suggested to be useful for adolescent anorexia (Cooper & Stewart, 2008)
● The rationale for the approach is that the patient with anorexia has distorted thoughts about shape and weight and an over valuation of thinness (Pike et al., 2004) which lead to severe dieting and over exercise to lose weight.
● CBT addresses these behaviors and thoughts through normalizing eating patterns, monitoring food intake through food logs, collaborative problem solving, behavioral experiments, and cognitive restructuring (Lock, 2010)
● Cognitive focus: address distorted cognitions related to body shape & weight that serve to maintain disturbed eating behaviors
● Behavioral focus: alter food restriction, binge eating, & purging behaviors
● Medical focus: monitor vitamin/mineral levels, restore electrolyte balance, develop nutrition plan (caloric requirements, etc)
