Psychopathology of Anorexia-Nervosa-tb-dg-cc-cw

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You will need sound for this presentation. Each slide includes narration and will transition to the next slide automatically. Please click the screen when you are ready to begin. 1 Music By: Superchick, “Courage”

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2 Psychopathology of Anorexia Nervosa

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Tedi Butolph, Christi Caballero, Dorinda Gatlin & Candace Wright Diagnostic Presentation In Partial Completion of the Requirements for Social Work 7371 Dr. Thompson Our Lady of the Lake University July 12, 2010 3

Definition of Anorexia Nervosa : 

Definition of Anorexia Nervosa Anorexia Nervosa (AN) is characterized by refusal to maintain a normal body weight, intense fear of weight gain, and distorted perceptions of body shape and size. Operationalized - low weight for AN is 85% of expected weight according to age and height. There are two types of AN: restricting type binge-eating/purging type (Comer, 2007; American Psychiatric Association, 2000) 4

Signs & Symptoms : 

Signs & Symptoms Physiological lower bone density 15% below expected BMI brittle nails and hair dry and yellowish skin growth of fine hair over body (e.g., lanugo) hair loss low body temperature low blood pressure slow heart rate electrolyte and metabolic imbalances cold hands and feet muscle weakness Anemia severe constipation Amenorrhea Lethargy (APA 2000; Comer, 2007; Gowers, 2006; NIMH, 2009; Wilson et al., 2007) Psychological/Sociological “intense fear of becoming overweight” distorted view of body shape and weight mood disturbance (depression, anxiety) feelings of ineffectiveness poor self esteem believes self-worth is dependent on scale measurement or ability to restrict food intake perfectionism Inflexible thinking restrained emotional expression changes in behavior (social withdrawal, obsessive behavior, substance abuse) 5

DSM-IV Criteria : 

DSM-IV Criteria “Refusal to maintain body weight at or above a minimally normal weight for age and height (e.g., weight loss leading to maintenance of body weight less than 85% of that expected; or failure to make expected weight gain during period of growth, leading to body weight less than 85% of that expected)” “Intense fear of gaining weight or becoming fat, even though underweight” “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 denial of the seriousness of the current low body weight” “In postmenarcheal females, amenorrhea, i.e., the absence of at least 3 consecutive menstrual cycles. (A woman is considered to have amenorrhea if her periods occur only following hormone, e.g., estrogen, administration” Specific Type: Restricting type: “during the current episode of AN, the person has not regularly engaged in binge-eating or purging behavior (i.e., self-induced vomiting or the misuse of laxatives, diuretics, or enemas)” Binge-Eating/Purging Type: “during the current episode of AN, the person has regularly engaged in binge-eating or purging behavior (i.e., self-induced vomiting or the misuse of laxatives, diuretics, or enemas)” (American Psychological Association, 2000) 6

Risk Factors : 

Risk Factors Female (90%-95%) Typical Onset between 14-18 About 50% have families that emphasize thinness Relative with eating disorder (six times greater risk) 33.8% with Comorbid diagnosis involving three or more disorders. The following are the most common: Anxiety disorder, ODD, CD, ADHD, Intermittent Explosive Disorder, Substance Abuse Disorder 58% with Eating Disorders have a Personality Disorder (avoidant or obsessive compulsive more associated with AN) 20%-50% with Eating Disorders have experienced Sexual Abuse Puberty onset prior to age 11 (female) Dieting practices in conjunction with unhealthy attitudes about self and unhealthy eating habits Through starvation, there are many health and psychological risks including death (by suicide, infection, electrolyte imbalances, gastrointestinal problems, or starvation itself) (Comer, 2007; Corcoran & Walsh, 2010) 7

Etiology & Neurobiology : 

Etiology & Neurobiology Societal values Society’s emphasis on thinness Subcultures (models, dancers, athletes, actors) Fuji Study (Comer, 2007; Costin, 2007) 8

Etiology & Neurobiology Cont. : 

Etiology & Neurobiology Cont. Family environment Dysfunctional Enmeshed Ineffective parenting Personal influences Unhappy with body image Low self-esteem Depression (often comorbid) (Comer, 2007; APA, 2000) 9

Etiology & Neurobiology Cont. : 

Etiology & Neurobiology Cont. Biological Genetic Set Weight Point Theory Lateral hypothalamus (LH) Ventromedial hypothalamus (VMH) Glucagon-like-peptide-1 (GLP-1) (Comer, 2007; APA, 2000) 10

Prevalence : 

Prevalence AN is has higher rates in developed countries (Cleveland Clinic for Continuing Education, 2010). In the United States an estimated 24 million people suffer from an eating disorder (Renfrew Center Foundation, 2010) Worldwide, up to 70 million individuals are believed to suffer from eating disorders (Renfrew Center Foundation, 2010) 11

Mortality Rates : 

Mortality Rates AN has among the highest mortality rate of the mental illnesses (South Carolina Department of Mental Health, 2006) 5-10% of those diagnosed will die within ten years of the diagnoses (South Carolina Department of Mental Health, 2006). 18-20% of those diagnosed will die within twenty years of the diagnoses (South Carolina Department of Mental Health, 2006). 12

Trends by Gender : 

Trends by Gender AN is most commonly diagnosed in the mid teens; however, in 5% of the patients onset is in the early twenties (Cleveland Clinic for Continuing Education, 2010) Female to male ratio of prevalence is between 6:1 and 10:1 (Cleveland Clinic for Continuing Education, 2010) 13 In up to 4% of adolescents and young adults eating disorders are reported (Cleveland Clinic for Continuing Education, 2010)

Lifetime Prevalence : 

Lifetime Prevalence AN in American women has a life time prevalence of 0.9% (Eating Disorders Coalition, 2008). AN in American men has a lifetime prevalence of approximately 0.3% (Eating Disorders Coalition, 2008). Only 30-40% of those diagnosed with AN will see full recovery from the disease (South Carolina Department of Mental Health, 2006). 14

Assessment Measures : 

Assessment Measures Additionally using an supplementary tools, such as: Eating Disorder Inventory (Comer, 2007) The Eating Disorder Inventory (Fairburn & Belgin, 1994) The Disorder Diagnostic Scale (Stice, Telch & Rizvi, 2000) The Eating Attitudes Test (Garner & Garfinkel, 1979) Body Satisfaction Index (Comer, 2007) (Corcocan & Walsh, 2006; Comer, 2007). 15 When assessing an individual for AN it is important to gather the client’s height, weight and body max index so that it can be compared to normal ranges for individuals of comparable age and gender (Comer, 2007).

Interventions : 

Interventions Systematic Review conducted by Bulk, Bekman, Bowley, Sedway and Leur (2007) Thirty-Two randomized controlled trials Goals were: Weight restoration Addressing Psychological issue Interventions reviewed were: Pharmacological Individual Therapy Family Therapy Cognitive-Behavioral Therapy 16 (Bulik, Berkman, Brownley, Sedway, and Lohr, 2007)

Pharmacological : 

Pharmacological 17 Amitriptylin and Cyproheptodine versus placebo 72 women ages 13-36 25% achievement in target weight Amitriptyline versus placebo 25 adolescents ages 11-17 No significant difference Fluoxetine versus placebo Women & men ages 16-45 3% difference in weight gain and psychological features Zinc versus placebo 54 women ages 15 and over 35% increase in BMI (Bulik, Berkman, Brownley, Sedway, and Lohr, 2007)

Individual Therapy : 

Individual Therapy Individual therapy versus family therapy 57 participants ages 14-55 years 5% drop out rate 18 (Bulik, Berkman, Brownley, Sedway, and Lohr, 2007) VS.

Family Therapy : 

Family Therapy Maudsley model included in therapy Adolescent 47-95% good outcome Conjoint family therapy versus separate family therapy 5% increase of eating and mood outcomes Weight outcomes remain the same Long term family therapy versus short term family therapy 86 participants ages 12-18 90% consisted mainly female 19 (Bulik, Berkman, Brownley, Sedway, and Lohr, 2007)

Cognitive-Behavioral Therapy : 

20 (Bulik, Berkman, Brownley, Sedway, and Lohr, 2007) CBT vs. nutritional education 33 participants ages 18-45 years Mainly female 9% reduced relapse risks Increased likelihood of good outcomes Favorable outcomes with adolescents No promising treatment w/adult Result of long duration w/disorder Cognitive-Behavioral Therapy

The Urban Myth : 

The Urban Myth AN is not just a middle class, white, teenage female issue. Eating Disorders cross all age, gender and cultural lines. 21

Cultural Considerations : 

Cultural Considerations African Americans report lower rates of AN (Costin, 2007) Of 13,454 Native American youth, over half of the girls and one third of the boys in the study practices some sort of diet or weight controlling behavior (Department of Health and Human Services, 2008). Anorexic Asian Americans report fewer signs and symptoms (Lee & Lock, 2007). 22 Breakfast. Lunch. Dinner.

Service to Hispanic Populations : 

Service to Hispanic Populations Rates: The Latino population in the United States has equal rates of AN compared to the White population (Costin, 2007). Treatment Considerations: Including the familial network (Shepard Pratt Health System, 2009). Cultural values (Falicov, 1998). Issues related to Acculturation vs. Assimilation (Department of Health and Human Services, 2008). 23

Bias in the Field : 

Bias in the Field Scenario: 16 year old female and her eating habits over a five day period □ Yes □ No 93 % Yes White vs. 79% Yes African American or Hispanic (Keel, 2005) 24

Age and Gender Considerations : 

Age and Gender Considerations Eating Disorders have increased by 400% with woman over the age of 30 years (Costin, 2007). The most common disorder being AN (Blinder, 2007). Men make up 5-10% of AN cases (Costin, 2007). Whenever there is an increased pressure to conform to an ideal body image, there is an increased risk for eating disorders Sheppard Pratt Health System, 2009). 25

Ethical Issues Related to DSM-IV : 

Ethical Issues Related to DSM-IV 26 A. Refusal to maintain body weight at or above a minimally normal weight for age and height (e.g., weight loss leading to maintenance of body weight less than 85% of that expected; or failure to make expected weight gain during period of growth, leading to body weight less than 85% of that expected). B. Intense fear of gaining weight or becoming fat, even though underweight. C. Disturbance in the way in which one's body weight or shape is experienced, undue influence of body shape on self-evaluation, or denial of the seriousness of the current low body weight. Type: Restricting Type vs. Binge-Eating/Purging Type D. In postmenarcheal females, amenorrhea, i.e., the absence of at least three consecutive menstrual cycles.

The Pro Ana Culture : 

The Pro Ana Culture 1. Keep a thinspiration book. Get a really nice journal or something and print pictures of skinny models, tips, quotes, or workouts, and glue it in there. Look through it whenever you want to binge. You can always download something from Prothinspo and keep it with you.2. Keep a stack of magazines weighing the same amount you want to lose. When you lose weight remove some magazines from the stack. It will be thinspirational to see that pile slowly start to get smaller. Use fashion magazines so that they also can inspire you as you remove as you lose.3. Eat on a blue or black plate. Dark colors usually make you feel fuller, faster. Better yet, eat on small dark plates.4. When you want to eat something you shouldn't, make a list of all the reasons you shouldn't, and read it at least 20 times.5. When you get a craving, count to 100 really slowly, and it might pass. Dr.s say that counting changes the minds direction in thought.6. If you live by yourself, put up motivational pictures or numbers on the unsafe foods. Stick your goal weight on the wall or on your favorite jar of peanut butter or jelly.7. Get one of those three ring binders and make a section for each part of the body. Put all the exercises you've got in there according to what body part there for.8. Pick one food for the day,look under the fat burning food section on this site or you can eat something  like an apple. Cut it into 4 quarters. Eat one part for breakfast, one for lunch, one for dinner, and you've got one left over for a snack.9. Take a Polaroid picture or a cell phone picture of yourself wearing nothing but your underwear. When you want to binge, look at it, and see all that fat that you need to get rid of? Carry it in your wallet  or phone whenever you go somewhere where there will be food.10. If you live by yourself and prone to binges, buy only the food you need for the day. That way if you eat it, there isn't anymore.11. Eat with the opposite hand you normally do. Left handed people eat with their right hand, and vice versa.12. Wear a rubber band around your wrist and snap it when you want to eat. You'll train yourself not to think about eating. This also works for trying to quit smoking.…. 1000 Tips on this one site: http://www.pro-thinspo.com/Tips.html 27

Summary : 

Summary 28 Characteristics: Refusal to maintain normal body weight Intense fear of weight gain Distorted perceptions BioPsychoSocial Theories Short-term and long-term effects No one is immune to disorder but certain populations are at a higher risk Treatment: Therapy Medication Cultural Competent Practice

References : 

References American Psychiatric Association (APA). (2000). Quick reference to the diagnostic criteria from the DSM-IV-TR. Washington, DC: American Psychiatric Association. Blinder, B. (2001). Anorexia nervosa in females over age twenty-five. Eating disorder specialist. Retrieved from www.ltspeed.com. Bulik, C. M., Berkman, N. D., Brownley, K. A., Sedway, J. A., & Lohr, K. N. (2007). Anorexia nervosa treatment: A systematic review of randomized controlled trials. International Journal of Easting Disorders, 40(4), 310-320. doi:10.1002/eat.20367 The Cleveland Clinic for Continuing Education. (2010). Disease Management Project: Eating Disorders. Center for Continuing Education. Retrieved from www.clevelandclinicmeded.com/medicalpubs/diseasemanagement/psychiatrypsychology/eating-disorders/#cesec10 Comer, R. J. (2007). Abnormal psychology complimentary (6th ed.). New York, NY: Worth Publishers. Corcoran, J., & Walsh, J. (2010). Clinical assessment and diagnosis in social work practice New York, NY: Oxford University Press. (2nd ed.). Department of Health and Human Services. (2008). Eating disorders information sheet: American Indian and Alaska native girls. Office of Women’s Health. Retrieved from www. Womenshealth.gov/bodyimage/. Eating Disorders Coalition. (2008). Research Studies. Eating Disorders Coalition For Research, Policy and Action. Retrieved from www.eatingdisorderscoalition.org/index.htm Falicov, C. (1998). Latino families in therapy: A guide to multicultural practice. New York, NY: The Guildford Press. Fairburn, C., & Beglin, S. (1994). Assessment of eating disorders: Interview or self-report questionnaire? International Journal of Eating Disorders, 16, 363-370. Garner, D. M., Garfinkel, P. E. (1979). The eating attitude test: An index of the symptoms of anorexia nervosa. (9th ed). Cambridge, England: Cambridge University Press. 29

References Cont. : 

References Cont. Gowers, S. G. (2006). Evidence based research in CBT with adolescent eating disorders. Child and Adolescent Mental Health, 11(1), 9-12. doi:10.1111/j.1475-3588.2005.00348.x Keel, P. K., (2005). Eating Disorders. Upper Saddle River, NJ: Pearson/Prentice Hall. Keel, K.P.,& Haedt, A. (2008). Evidence-based psychosocial treatment for eating problems and eating disorders. Journal of Clinical Child & Adolescent Psychology. 37(1), 39-61. Lee, H.Y., Lock, J. (2007). Anorexia nervosa in Asian-American adolescents: Do they differ from their non-Asian peers. International Journal on Eating Disorders. Retrieved from Interscience. Lock, J., & Gowers. S.(2005). Effective treatment for adolescents with anorexia nervosa. Journal of Mental Health. 14(6), 599-610. National Institute of Mental Health (NIMH). (2009). Anorexia nervosa. Retrieved April 10, 2010, from http://www.nimh.nih.gov/health/publications/eating-disorders/AN.shtml Reinblatt, S. P., Redgrave, G. W., & Guarda, A. S. (2008). Medication management of pediatric eating disorders. International Review of Psychiatry, 20(2), 183-188. doi:10.1080/09540260801889120 The Renfrew Center Foundation. (2010). Research: A Greater Understanding of Eating Disorders. The Renfrew Center Foundation Advancing the Education, Prevention, Research, and Treatment of Eating Disorders. Retrieved from www.renfrew.org Sheppard Pratt Health System. (2009). Eating disorder misconceptions. The center for eating disorders at Sheppard Pratt. Retrieved from www.eatingdisorders. org. South Carolina Department of Mental Health. (2006). Eating Disorder Statistics. Department of Mental Health. Retrieved from www.state.sc.us/dmh/anorexia/statistics.htm Stice, E., Telch, C. F., & Rizvi, S. L. (2000). Development and validation of the eating disorder diagnostic scale: A brief self-report measure of anorexia, bulimia, and binge-eating disorder. Psychological Assessment, 12, 123-131. Wilson, G. T., Grilo, C. M., & Vitousek, K. M. (2007). Psychological treatment of eating disorders. American Psychologist, 62(3), 199-216. doi:10.1037/0003-066X.62.3.199 30

Thank you for your time and consideration. : 

Thank you for your time and consideration. 31