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Transcript of Eating Disorders
An eating disorder is defined as an illness in which victims suffer from severe disturbances in their eating behaviours and related thoughts and emotions (APA, 2011).
The primary characteristic of those with Anorexia Nervosa (AN) is that they refuse to maintain or gain weight at even a minimal developmental level. They have an intense fear of weight gain, a severe disturbance in the way they perceive their weight or body shape. They also have underlying hormonal abnormalities second to weight loss (Madden 2004)
AN is the 3rd most common chronic disorder in adolescent girls (affecting 0.5-1%) and one tenth as many boys (Dey, 2004; Madden, 2004).
After ten years the mortality rate is 10% (Madden,2004) and the lifelong mortality rate is 15% (Dey,2004).
Individuals with AN are so successful at losing weight that they put their lives in danger. People suffering from AN often are proud of their diets and show extraordinary self control.
Severe, almost punishing exercise is common
Two types of Anorexia Nervosa:
Binge eating-purging type
The binge-eating purging type is different to bulimia as they tend to binge on small amounts of food and purge more consistently.
Those who have Bulimia Nervosa (BN) differ from those with AN as they are not as successful at losing weight. people with AN tend to have great self control where as BN is typically associated with being ashamed of the problem and feeling as thought they lack control.
Binge-Eating Disorder (BED) is not a disorder listed in the DSM-IV-TR. It is however, under consideration for the DSM-V.
People with BED experience distress due to binge eating but to not engage in compensatory behaviours.
The DSM-IV-TR includes in the section titled Eating Disorders:
binge eating/ purging type
Eating Disorder Not Otherwise Specified
Listed in the appendix as a diagnosis for further study is Binge Eating Disorder.
Proposed changes to the criteria of eating disorders in DSM V include:
Reclassifying the category and naming it "
Feeding and Eating Disorders"
This will result disorders such as: Pica, Rumination Disorder, Avoidant/ Restrictive Food Intake Disorder being included in the Feeding and Eating Disorders category
Binge Eating Disorder
recognised as a free-standing diagnosis.
Eating disorders began to increase in the 1950s and early 1960s.
Bulimia Nervosa became an eating disorder in 1970.
Eating disorders increased dramatically in Western cultures between 1960 and 1995 (Barlow & Durand, 2005)
Until recently eating disorders tended to be cultural specific. Now it appears to be going global.
Despite this 90% of severe cases are females from middle-upper class backgrounds (Barlow & Durand,2005).
More common than Anorexia
Menstruation ceases (amenorrhea).
Dry skin, brittle hair or nails, sensitivity to cold temperatures
'Lanugo' - downy hair on limbs and cheeks.
In purging type electrolyte imbalances occur which in turn cause cardiac and kidney problems.
Cardiovascular problems- eg. low blood pressure, heart rate & unstable heart rhythyms
Brain blood flow shut down.
(Barlow & Durand, 2005; Nunn, 2004)
Associated Psychological Disorders
Anxiety and Mood disorders are the most common.
current depression occurred in 33% of cases and 60% of people with AN had depression at some point.
An anxiety disorder that commonly co-occurs is OCD as people with anorexia often have a variety of rituals and behaviours to rid themselves of unpleasant thoughts.
Substance abuse is common and a strong predictor or mortality/ suicide
"Bulimia Nervosa is characterised by recurrent episodes of uncontrolled eating and inappropriate compensatory behaviours such as vomiting, over exercising and laxative abuse to lose weight, but without the severe weight loss of anorexia" (Madden, 2004).
Individuals with Bulimia tend to stay within 10% of normal weight.
They tend to eat larger amounts of food, comprised of more junk foods than the fruits and vegetables that other people eat (Wilson & Pike, 2001).
although calorie intake varies significantly from person to person.
The DSM-IV-TR classifies two types of BN:
Non-purging compensation includes vigorous exercise and fasting between binges.
Problems with DSM diagnoses:
The non-purging type is rare accounting for 6-8% of those with BN (Striegel-More et al, 2001).
Classifying females before onset of menstruation
Individuals who have the physical features but not the cognitive aspects.
The 2 subtypes often co-exist.
Purging is not an effective weight loss technique, vomiting immediately after food is ingested only reduces 50% of calories. Laxatives have little effect.
Individuals with eating disorders tend to determine their self esteem by their weight and body shape.
Salivary gland enlargement, giving the face a chubby appearance.
Erosion of enamel on teeth and electrolyte imbalance.
Intestinal problems including colon damage and constipation
Associated Psychological Disorders
Anxiety and mood disorders are common.
Historically there have been theories that depresssion is the cause of BN however, studies have shown that depression follows BN and may be a reaction to it (Brownwell & Fairburn, 1995).
People with BED are often found in weight control programs.
30% of obese people meet the criteria for BED.
People with BED share the same concerns about shape
and weight as people with AN and BN.
Not formally an eating disorder in the DSM.
The prevalence of obesity is so high that it is statistically
if it weren't for the serious health, social and psychological implications it entails.
The core problems is eating more and exercising less than an individual who does not have obesity.
Consequences of obesity include:
Gall bladder disease
Muscular skeletal problems
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 (e.g., within any 2-hour period), an amount of food that is definitely larger than 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 (for example, a feeling that one cannot stop eating or control what or how much one is eating)
B. The binge-eating episodes are associated with 3 (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 after overeating
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 and does not occur exclusively during the course Bulimia Nervosa or Anorexia Nervosa.
DSM V- BED
Relatives of those with eating disorders are 4-5 times more likely to develop an eating disorder.
no clear agreement on what is inherited: personality traits?
Abnormalities in blood flow and metabolsim specific to anorexia rather than starvation. These abnormalities occur in the part of the brain affecting emotion regulation.
low self esteem and self control
preoccupied with appearance
experience social anxiety
AN and BN are the most culturally specific psychological disorders identified.
Western cultures value appearance more than health.
Cultural pressures trigger eating disorders.
eg. professions with high pressure to be thin such as modeling and ballet dancing have higher rates of eating disorders (Madden, 2004)
perfectionistic mothers who want their daughters to be thin.
families that value external appearance and are eager to maintain harmony than discuss negative topics.
•Interventions will vary depending on nature and severity of the eating disorder, as well as age and family situation.
•Observations, Interviews and Formal Psychometric Assessments
•Self Report Questionnaires
- Children’s Eating Attitudes Test (ChEAT; Maloney, McGuire & Daniels, 1998)
- Children’s Eating Disorders Inventory (EDI-C; Garner, 1991)
- The Eating Disorder Examination Questionnaire (EDE-Q; Fairburn & Beglin, 1994)
- Children’s Eating Disorder Examination (ChEDE; Bryant-Waugh et al., 1996)
- Development and Well-being Assessment (DAWBA; Goodman et al., 2000)
•Inpatient Treatment/hospitalization – 24 hour for medical, nutritional and psychiatric help.
•Outpatient Treatment – ongoing support with team of health professionals in a clinic.
•Day Programs – attend up to 5 days a week and taper down, usually imvolves structured eating sessions and active treatment.
•Community Based organizations – helpful for providing access to support and information
•Rural Options?? Difficult
The National Eating Disorders Collaboration website provides a search for treatment centres/options available near you based on age.
Goals of Treatment:
Restore physical health, normal eating patterns
Reduce impact of the eating disorder on quality of life
Restore normal nutritional and physiological state
Requires involvement of interdisciplinary team (medical, psychological and nutritional) and in the case of the adolescent, usually the family.
•Treatment focus initially on reversing malnutrition and preventing physical complications from starvation – sometimes hospitalization/refeeding through tubes under supervised conditions.
•Other times outpatient but still utilising medical, psychological and dietary (nutrional) management team.
Family Based Treatment (FBT)
Family Therapy for treatment of Anorexia Nervosa in adolescents has received support from research.
-Parental empowerment to reefed their child through decreasing anxiety and guilt. Reinforcing healthy family structure-Clear and non-punitive limits. Parents take charge and set up hierarchy in terms of food (non-punitive) while fostering independence, communication and control in other areas.
-Externalising the disorder – i.e. the disorder is the problem not the child. This is to help shift patterns of conflict and critisism between parent and child.* In most cases it is best to assume the parent is caring and concerned about their child (reassessing the stigma that half the reason for the problem is the parents in the first place; Madden, 2004).
* Central to recognize that AN is a chronic disorder lasting often 5 years thus rarely instantaneous success.
Jones et al. (2012) found an online FBT model (P@N/E@T) was successful in reducing risk status and early symptoms of AN.
Online format: ease of dissemination, readily adapted and updated, 24 hour content, permits interactivity (attractive/engaging format), generates automatic database and may reduce cost. - parents educated on the nature of the disorder and the need to intervene.
- Encouraged to take definitive steps to prevent further weight loss.
- Focused on activating parental control and empowerment, providing practical approaches, assisting parents with problem solving skills and provide guidance about ongoing monitoring.
– there have been a large number of treatment studies demonstrating the efficacy of CBT for use with adult BN patients. A modified version for adolescents has been proposed and is currently used in practice.
• Assumes the main factors maintaining the disorder are dysfunctional attitudes towards body shape and weight. Modifications of the treatment for adolescents include
1) increased attention to theraputic alliance early on
2) including parents re: educating about CBT and their role
3) less abstract language and concrete examples in educating about CBT
4) exploring adolescent concerns in the context of BN
Internet Prevention Groups
Taylor et al (2006) showed that a brief 8 week internet-based cognitive behavioural intervention led to substantial reductions in weight and shape concerns in college-aged women at risk of developing BN and BED. - Participants logged on each week and read various content regarding a weekly program, completed assignments i.e. participating in discussion group, self-monitor, and/or writing journal entries in a personal or body image journal. Discussion groups moderated by clinical psychologist.- Weekly email reminders sent - Assessed at one year and 2 years post-intervention found the Weight Concerns Scale scores decreased more in the intervention group than the control group.
- Can be useful for treating comorbid disorders. Should be used in conjunction with psychotheraputic interventions
- Antidepressants = effective in treating BN and BED
- Antipsychotics = may be useful for patients with AN (alleviates rumination, agitation and delusional thinking)
-However research still in early stages and efficacy of medications for adolescents controversial.
• Usually 20 sessions over 6 months in a
3 stage model:
Stage 1 –
present model, structure and goals, likely outcome, education re eating disorders and weight regulation, establish self-monitoring habits (journal/food record), apply graded behavioural techniques.
Stage 2 –
Cognitively-oriented treatment. Identify and modify thoughts and attitudes maintaining the disorder (triggers etc), supplemented by behavioural experiments. Modify patients extreme concerns about shape and, for the adolescent, weight and problem-solving techniques for problematic thoughts (rather than formal cognitive re-structuring)
Stage 3 –
Maintenance of the change/ relapse prevention strategies. Includes identifying adolescent stressors that may lead to relapse. 4-5/20 will be parent collateral meetings.
Many other forms of psychotherapy are also used to treat eating disorders.
Some of these include:
Cognitive analytic therapy
Crisis-intervention (for BN)
Dialectical Behavioural Therapy
Ego Oriented Individual Therapy
Focal Psychoanlytic Therapy
All forms of eating disorders:
Need immediate and ongoing management.
Given the high rates of relapse, recurrence, crossover (to other eating disorders) and comorbidities. Need sufficient frequency, intensity and duration of treatment. Some suggestion that may need mental health treatment for several years.
Treatment can be time consuming, prolonged and costly.
Implications for School Counsellor
School Counsellors are in a position to:
Identify at risk individual
Implement effective school-based prevention strategies
Provide support for recovering students (Bardick et al., 2004)
Needs to be taken very seriously given the long-lasting, often irreversible and potentially fatal impacts eating disorders can have on the body, and mentally.In many cases we will need to refer the child for treatment by other professionals – medical doctors, nutritionists. The time and effort required to monitor and treat an individual with an Eating Disorder is probably not the job solely of the School Counsellor
- May need to work with treatment team to reintegrate student in to school, and support student with supportive counselling, meal monitoring, communication with treatment team and family. May also need to support the student with relief from classes (e.g. PD/H/PE).
- Preventative measures will be important. Hold workshops on media literacy, assertiveness and coping strategies. Educate about the negative impacts of eating disorders. (Grave, 2011)
- School Counsellors should be aware of the existence of ‘pro-ana’ and ‘pro-mia’ websites. They encourage the persistence of the disordered eating and view it as a lifestyle choice rather than a disorder. S.Cs should be providing resources for students where they can find helpful and reputable information online. http://anabootcamp.weebly.com/rainbow-diet.html
- S.Cs should explore their own beliefs, values and practices about weight, dieting and body image to identify how attitudes may inadvertently affect children. (Bardick et al., 2004)
Some other issues to explore when treating (in brief) an individual with an Eating Disorder:
Issues with self-concept/self esteem
Autonomy and capacity for intimacy – to be addressed in developmentally appropriate ways
Consider family life and family’s role in the person’s life. Comorbidities will need to be closely monitored/ evaluated carefully. Ie. Depression, anxiety, substance abuse, personality disorders, other forms of self-harm. Encourage and reinforce positive attitudes and behaviours.