College 4 - ED Flashcards
ARFID
Avoidant/Restrictivee Food Intake Disorder (ARFID)
A. Eating or feeding disturbance (including but not limited to apparent lack of interest in eating or food; avoidance based on the sensory characteristics of food; or concern about aversive consequences of eating) as manifested by persistent failure to meet appropriate nutritional and/or energy needs associated with one or more of the following:
1.Significant weight loss (or failure to gain weight or faltering growth in children);
2.Significant nutritional deficiency;
3.Dependence on enteral feeding
4.Marked interference with psychosocial functioning
B. There is no evidence that lack of available food oran associated culturally sanctioned practice is sufficient to account alone for the disorder
C. The eating disturbance does not occur exclusively during the course of Anorexia Nervosa or Bulimia Nervosa, and there is no evidence of a disturbance in the way of which one’s body weight or shape is experience
D. If the eating disturbance occurs in the context of a medical condition or another mental disorder, it is sufficiently severe to warrant independent clinical attention
AN
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: less than that minimally expected.
B. Intense fear of gaining weight or of becoming fat, or persistent behavior that interferes with weight gain, even though at a significantly low weight.
C. 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.
Severness
Mild:BMI (Body Mass Index) > 17
Moderate: BMI 16 –16.99
Severe: BMI 15 –15.99
Extreme: BMI < 15
BN
A. Recurrent episodes of binge eating:
*Eating within 2 hrs. amount of food larger than what most individuals would eat etc.
*Sense of lack of control
B. Recurrent inappropriate compensatory behavior in order to prevent weight gain
C. Both occurring at least once a week for 3 months
D. Self-evaluation unduly influenced by body weight/shape
E. Not only during episodes of anorexia nervosa
Mild 1-3/wk. vs Extreme 14 or more/wk
Binge eating disorder
A. Recurrent episodes of Binge Eating: more than others/lack of self control.
B. 3 or more of the following:
Eating more rapid
Eating until feeling uncomfortable full
Large amounts when not hungry
Eating alone because of embarrassment
Feeling disgusted/depressed/guilty afterwards
C. Marked distress regarding binge eating
D. On average once a week for 3 months
E. No compensatory behavior/not AN/B
Other specified feeding or eating disorders
1.Atypical AN > normal weight
2.BN of low frequency/limited duration
3.BED of low frequency/limited duration
4.Purging disorder: purging, but no bingeing
5.Night eating syndrome
6. Orthorexia
PICA
A.Persistent eating of nonnutritive nonfood substances at least 1 month.
B.Inappropriate to development
C.Not part of culturally /socially normative practice
D.If in context of another mental disorder, then sufficient severe to warrant additional clinical attention
Rumination disorder
A.Repeated regurgitation at least for 1 month.
B.Not attributable to associated gastrointestinal or other medical condition
C.Not exclusively during AN/BN/BED/ARFIDD. If in context of another mental condition, then sufficiently severe to warrant additional clinical attention
Treatment
AN - FBT, EFFT, CBT, CBT-E
BN - CBT, CBT-E
BED - CBT, CBT-E
ARFID - N/A
* afhankelijk van leeftijd
main challenges FBT
- person not always at home
- non specified eating schedule
- variable efficiency in speed recovery
- child/adolescent involvement
- families find it difficult
- role of depression & anxiety not treated
- resistance of children/adolescents
CBT-E stages
four stages:
- gain understanding of eating problem, stabalize pattern of eating, personalized education & adressing concerns about weight
- prgress is systematically reviewed & plans are made for main body of treatment
- focused on processess that are maintaining the persons eating problem
- emphasis on changes to future, focus on dealing with setbacks & maintaning changes obtained
Cognitive Behavioral Therapy – Enhanced (CBT-E)
- Treats an individual’s particular symptomatic behaviors vs. treating ED
diagnoses generically (as in CBT) - Transdiagnostically effective
- Reduces ED behaviors, psychopathology, and increases BMI.
- Not significantly more effective than other treatment methods
- Preferred by parents over FBT for older adolescent
EFFT aims
➢ Equip caregivers to assist in the child’s refeeding and
interruption of symptoms.
➢ Assist caregivers to become ‘emotion coaches’ for the
child.
➢ Enable effective and specific treatment of both behavioral
and emotional difficulties related to the ED
alexithymia
inability to recognize/label motions
> characteristic ED
> ED to control affect
role parents in EFFT - Lafrance
parents as emotional coaches
> making ED unneccessary to cope with painful emtional experiences
primary aims EFFT - Lafrance
- helping parents to support their childs refeeding & interruption of symptoms
- supporting parents to become emotion coach
Phases EFFT - Lafrance
- Parents are experts on child and therapist is expert on eating disorders.
Parents are experts on child and therapist is expert on emotion.
Parents are supported to refeed and interrupt symptoms as if tending to a younger child.
Parents are supported to become child’s emotion coach and identify miscues.
‘Feed the baby’
‘Rock the baby’
- Parents gradually return control of eating over to their child.
Parents develop an increased ability to be their child’s emotion coach, including ‘speaking the unspoken.’
Therapist explores child/adolescent issues and the development of ED.
Parents share the responsibility for past injuries/losses to free the child from her own crushing self-blame.
- Therapist assists the family to return to normal life cycle.
Parents continue to respond to the child’s emotions/soothe. The child’s capacity for self-soothing continues to emerge.
Therapist assists the family in supporting child’s journey towards development of healthy identity.
Therapist supports the parents in processing their own emotional reactions to the child’s individuation and identity development.
general principles for all ED treatment - Hay
- person centered informed decision making
- involving familie and signif others
- recovery oriented practice
- least restrictive treatment context
- multidisciplenary approach
- stepped and seamless care
- dimensional & culturally. informed approach to diagnosis & treatment
- indigenous care
treatment priorities in AN - Hay
- engagement
- medical stabilisation
- medical complications & their treatment
- reversal of cognitive effects of starving
- psychological treatment
> monotoring progress and reviewing priorities
Assessment anorexia nervosa in children and adolescents - Hay
At assessment, every child or adolescent suspected of having anorexia nervosa needs a comprehensive review of psychological and physiological signs and symptoms.
Assessment should involve both children and their families or carers unless this is contraindicated due to safety concerns such as abuse or domestic violence
Assessments in children and adolescents should be developmentally informed.
Psychological assessment should include a review of both eating disorder symptoms and comorbid psychiatric symptoms (e.g. OCD or MDD)
Treatment AN - Hay
firstline: outpatient treatment (involve family)
inpatient however for medical instability
Treatment, especially of children and adolescents with more severe disease, should be multidisciplinary, and include focused psychological therapy of the eating disorder and comorbid psychological problems. It should typically include psychoeducation of families, nutritional and medical therapy (at times pharmacotherapy) and may require case management involving schools and other agencies.
psychotherapy: FBT is first line, however family problems > individual therapy (AFT and eating disorder specific CBT, with little evidence to support TAU)
Pharmacotherapy: there is insufficient evidence to recommend psychotropic medication in adolescents with anorexia nervosa. The use of anxiolytic or antidepressant medications to relieve symptoms should be done with caution
The outcomes for young onset eating disorders appear generally better than for older adolescent and adult onset eating disorders.
Assessment BN - Hay
(a) behaviours, namely binge eating & weight control behaviours that may or may not be compensatory for binge eating
(b) cognitions of weight and/or shape overvaluation, and body image and eating preoccupations. + history of other eating disorders, especially anorexia nervosa, as this may be associated with increased likelihood of relapse and a poorer outcome + other psychiatric comorbidities + physical examination
treatment BN - Hay
Psychological therapies. First-line treatment for bulimia nervosa and binge eating disorder in adults is an individual psychological therapy
> CBT, CBT-E has been found more efficacious than other psychological approaches
> 4 stages: begins with psychoeducation and a CBT informed formulation of the processes maintaining the person’s disorder, and uses it to identify problems to be targeted in therapy. This is followed by the introduction of monitoring of key behaviours, establishment of regular meals and snacks, and within session weighing (sessions 1–7 over one month). The second stage (sessions 8 and 9, weeks 5 and 6) is a ‘taking stock’, or reflection and review phase with revisiting and modification of the formulation as appropriate. The third stage (sessions 10–17, weeks 7–14) is a personalised program where the main mechanisms maintaining the eating disorder are addressed. Stage 4 (sessions 18–20, weeks 15–20) looks to the future, ensuring improvements are maintained and includes relapse prevention
- when no access to therapist: CBT or selfhelp: Pure or unguided selfhelp may be effective in binge eating disorder; however, it has poorer outcomes compared to guided self-help CBT or specialist provided CBT in bulimia nervosa
- Pharmacology: RCTs and meta-analysis have found that tricyclic antidepressants may be efficacious for people with bulimia nervosa but adverse effects limit clinical utility
> high dose fluoxetine (60mg/day) is effective for people with bulimia nervosa and this or other SSRI antidepressants are effective for both bulimia nervosa and binge eating disorder. The antiepileptic topiramate also is effective in both conditions and is associated with weight loss. However, topiramate may cause problematic side effects such as paresthesias and taste perversion
> if psychotherapy is not available, or alone not enough, or when comorbid
