abnormal quiz 3 Flashcards
Diagnosis anorexia
- Persistent 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)
- Either an intense fear of gaining weight or of becoming fat, or persistent behaviour that interferes with weight gain (even through significantly low weight)
- Disturbance in the way one’s body 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
types of anorexia
- Restricting type: during the last 3 months, the individual has not engaged in recurrent episodes of binge eating or purging behaviour (i.e. self-induced vomiting or the misuse of laxatives, diuretics or enemas). This subtype describe presentations in which weight loss is accomplished primarily through dieting, fasting, and/or excessive exercise
- Binge-eating/purging types: during the last 3 months, the individual has engaged in recurrent episodes of binge eating or purging behaviour (i.e. self-induced vomiting or the misuse of laxatives, diuretics or enemas)
Alternative conceptualisations: embodiment (anorexia)
- The bio-psycho-social paradigm defines and categorises anorexia as a ‘disturbance in the way in which one’s body weight or shape is experienced’
- Conceptualising anorexia within the broader construct of embodiment enables the inclusion of a range of embodied experiences
- An embodied framework departs from the cartesian mind-body dualistic impression of human functioning to emphasize the interactions between the mind, the body, and the self within their social structures
- Embodiment theory enables researcher to anchor enquiry into the bod by shifting the vantage point from an externally driven orientation to the subjective experience of the ‘body-subject’ that is experientially aware and connected to feelings and sensations of the corporeal body
Alternative conceptualisations: feminism (anorexia)
•Feminist approaches have sought to situate ED’s in relation to the wider social expectations surrounding western femininity, ranging from gendered discourses on appetite, sexuality, economic power to social roles
- Not about magazines
– not cultural but structural
-Who owns women’s bodies in our society?
•Anorexia can be seen as a culture-bound syndrome, understood as a cultural metaphor for issues of control, compliance and body ownership in a patriarchal system
Medical risks (anorexia)
- neurological
- Metabolic
- Cardiovascular
- Haematological
- Renal
- Endocrine
- Musculo-sketal
- Gastroenterological
- Immunological
Indications for hospitalisation anorexia nervosa
- Physiological instability
a. Severe bradycardia (heart rate < 50 beats/minute daytime; <45 beats/minute night time)
b. Hypotension (<80/50 mmHg)
c. Hypothermia (<35.5 degrees Celsius)
d. Orthostatic changes in pulse (>30 beats/minute) or blood pressure (>10 mmHg) - Cardiac arrhythmia
- Electrolyte disturbances (hypokalaemia, hyponatraemia and hypophosphatasemia)
- Severe malnutrition (weight <75% IBW)
Prognosis (anorexia)
- The risk of successful suicide is 32 times that expected, compared with major depression in which death form suicide is 21 times greater than expected
- The average duration of illness is 7 years
family therapy (anorexia)
• One exception is a family therapy for adolescents which focuses on enabling parents to refeed their child… appears promising… unclear whether this approach is superior to other types of family therapy or to individual therapy, hence it cannot be recommended as an evidence-based treatment at this point
- Child living at home and developed anorexia - Therapist gets the parents to take control a home - Stop the child exercising - Watch the child eat the whole meal - Make sure the parents aren’t arguing - Don’t blame the child - Prevent hospitalisation as it can become a cycle
DSM- 5 criteria: bulimia nervosa
• Recurrent episodes of binge eating. An episode of binge eating is characterized by both o 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)
• Recurrent inappropriate compensatory behaviours in order to prevent weight gain, such as self-induced vomiting; misuse of laxatives, diuretics or other medications; fasting; or excessive exercise
• The binge eating and inappropriate compensatory behaviours both occur, on average, at least once a week for 3 months
• Self-evaluation is unduly influenced by body shape and weight
• The disturbance does not occur exclusively during episodes of anorexia nervosa
• Specify if:
-In partial remission: after full criteria for bulimia nervosa were previously met, some, but not all, of the criteria have been met for a sustained period of time
- In full remission: after full criteria for bulimia nervosa were previously met, none of the criteria have been met for a sustained period of time
Epidemiology of bulimia nervosa
- came to attention of professionals in the 1970’s
- occurs predominately in women
- co-varies with dieting
comorbid conditions (bullimia)
- substance abuse
- depression
- suicidality
- personality disorders
- anxiety disorders
CBT (bullimia)
•CBT: cognitive behavioural therapy
- Usually lasts 20 weeks - Semi-structured - Problem- orientated - Concerned with present and future (rather than past) - 3 stages of treatment
• The aims of stage 1 - CBT
- To establish a sound therapeutic relationship - To educate the patient about cognitive view on the maintenance of BN and to explain the need for both behaviour and cognitive change - To establish regular weekly weighing - To educate about body weight regulation, adverse effects of dieting, physical consequences of binge eating, self-induced vomiting and laxative abuse - To reduce the frequency of overeating by introducing a pattern of regular eating and the use of alternative behaviour - To reduce secrecy and enlist the cooperation of friends and relatives
• The aims of stage 2 (sessions 9-16)
- Tackling dieting - Enhancing problem-solving skills - Addressing concerns about shape and weight - Addressing other cognitive distortions
•The aims of stage 3 (sessions 17-19)
- 3 interviews at 2 week intervals - Aim is to ensure that progress is maintained - Relapse prevention
Therapist skills (bullimia)
- Technical competence
- Establishing an effective therapeutic relationship
- Nurturing a commitment to change
- Maintaining a specific therapeutic focus
- Expertise and experience
Therapeutic relationship (bullimia)
- Be credible
- Be caring and non-judgemental
- Develop a collaborative relationship
- Balances empathy with firmness
- Be positive
- Gender issues
Medical complications (bullimia)
The clinician should never under-estimate the risk of medical complications of BN, despite apparent normal weight. Potential medical problems such as electrolyte imbalance from repeated purging, to actual damage to heart muscle and other organs should be investigated by a full medical evaluation/examination and appropriate laboratory investigations
The elimination of dieting (bullimia)
- Stress the importance of ceasing to diet and provide education abut weight gain
- Assess food avoidance and systematically introduce avoided foods into planned meals or snacks (therapist-assisted exposure)
- Relax other controls over eating
Importance of prescribed regular eating pattern (bullimia)
- It begins to break down dieting
- It restores a sense of control
- I disrupts learned association between urges/triggers (emotional and situational) to eat or binge
Sexual Abuse and Eating Disorders
*Sexual abuse violates the boundaries of the self so dramatically that inner sensations of hunger, fatigue, or sexuality become difficult to identify. People who have been sexually abused may turn to food to relieve a wide range of different states of tension that have nothing to do with hunger. It is their confusion and uncertainty about their inner perceptions that leads them to focus on the food.
• Many survivors of sexual abuse often work to become very fat or very thin in an attempt to render themselves unattractive. In this way, they try to de-sexualize themselves
• Sexual abuse and emotional eating both have one element in common. It is secrecy. Many eating disorder patients feel guilty about the sexual abuse in their childhoods, believing they could have prevented it but chose not to because of some defect in themselves.
• To date, no treatments have been developed specifically for clients with comorbid PTSD and eating disorders.
DSM-5 binge eating disorder
• Recurrent episodes of binge eating. An episode of binge eating is characterised 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 people would eat in a similar period of time under similar circumstances
•NB. Objectively large amounts of food e.g. 1 loaf of bread, 1L of ice cream, a few bowls of cereal, a family sized chocolate block
2. A sense of a lack of control over eating during the episodes ( e.g. a feeling that one cannot stop eating or control what or how much one is eating)
- Some individuals report a ‘dissociative quality’ during or following binge-eating
• NB. Some people feel that they are ‘bingeing’ when they do not have objectively large amounts of food (e.g.. break a diet by eating a few chips or a piece of cake. If loss of control is present, this constitutes a subjective binge episode
b. the binge-eating episodes are associated with three or 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
c. Marked distress regarding binge eating is present
- Individuals with binge eating disorder are typically ashamed of their eating problems and attempt to conceal their symptoms. Binge eating usually occurs in secrecy or as inconspicuously as possible
d. The binge eating occurs, on average, at least once a week for 3 months
Bing eating disorders vs bulimia nervosa
e. The binge eating is not associated with the recurrent use of inappropriate compensatory behaviour as in bulimia nervosa and does not occur exclusively during the course of bulimia nervosa or anorexia nervosa
Specifiers for binge eating
• Specifiers – current severity: the minimum level of severity is based on the frequency of episodes of binge eating. The level of severity maybe be increased to reflect other symptoms and the degree of functional disability
- Mild: 13 binge-eating episodes/week - Moderate: 4-7 binge-eating episodes/week - Severe: 8-13 binge eating episodes/week - Extreme: 14 or more binge-eating episodes/week
Binge eating disorders associated with:
- Early onset obesity
- severity of obesity
- increased rates of psychopathology
relationship between binge eating and obesity
- 41% of overweight/obese in the comity meet the criteria for one of the binge eating illnesses
- 52% of overweight and obese in weight loss programs meets the criteria for one of the binge eating illnesses
- 88% individuals with binge eating disorder had obesity at some point in their lives
How abnormal is binge eating?
- Time trends in population prevalence and burden
- Health-related quality of life (HRQoL) impairment attenuated over time, such that those reporting recurrent binge eating scored similarly to the population norms on the measures of HRQoL
- Weekly binge eating no longer associated with increased days out of role compared to 2005
- And in 2015, -50% of respondents who report weekly or twice weekly binge eating report that they do not experience distress related to the act of binge eating, but distress experience is related to QoL impairment and higher number of days out of role
Risk factors (binge eating)
- Binge eating disorder appears to run in families, which may reflect genetic influences: 17%- 39% of the variance
- Dieting is greatest risk factor of developing binge eating disorder
- Other risk factors: trauma (especially early-life), low self-esteem, body dissatisfaction, negative emotionality, overvaluation of the importance of weight and shape, difficulty regulating emotional states, parental substance abuse
- Triggers for binge eating include: negative affect, interpersonal stressors, dietary restraint, boredom
Comorbid conditions (binge eating disorder)
- Binge eating disorder similar to other eating disorders in terms of comorbidity
- Depression and anxiety disorders most common (-54% have comorbid depression; -37% have a comorbid anxiety disorder)
- Substance use and personality disorders are also common (-25%)
- Few gender differences observed; men had higher lifetime rates of substance use disorders and current rates of obsessive compulsive disorder
Assessment tools (binge eating disorder)
- SCOFF, a 5-item screening tool. Administration and scoring is very simple, but it is not binge eating disorder or binge eating-specific. It also covers other eating disorder behaviours
- Binge eating scale (BES) is a 16-item self-report scale and scoring is slightly more complicated than the SCOFF, but it is specific to binge eating
- BEDS-7, a 7 item diagnostic screener which follows the DSM-5 criteria for binge eating disorder
Treatment for binge eating
- Cognitive behavioural therapy (CBT) most common (-70% studies)
- Dialectical behavioural therapy (DBT)
- Interpersonal psychotherapy (IPT)
- Brief strategic therapy (BST)
- Behavioural weight loss (BWL)
Hapifed definition
a heathy approach to weight management and food in eating disorders
Hapifed
• The problem
- Psychological therapies for binge eating disorder while impacting binge frequency do not lead to weight reduction
• The solution
- Integrate the best of behavioural weight loss with cognitive behaviour therapy
- Sustain weight loss by reducing disordered eating, enhancing psychological wellbeing and improving appetite regulation.
