assessing & treating eating disorders kayj nash okine, ph.d. chrysalis center for counseling...
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Assessing & Treating Eating Disorders
Kayj Nash Okine, Ph.D.
Chrysalis Center for Counseling & Eating Disorder Treatment
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The Continuum Model of Eating Disorders
NORMAL EATING
WEIGHT PREOCCUPATION
CHRONIC DIETING
BINGE EATING
PURGING
SUBCLINICAL EATING DISORDER
CLINICAL EATING DISORDER
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When Does An Eating Disorder Exist?
ED behaviors satisfy psychological needs. One’s food intake & weight affect one’s
feelings about work, school, relationships, self. Body image & desire to lose weight affects,
and becomes the basis for, decisions. Desire to lose weight & engage in ED
behaviors becomes more important than anything else.
ED behaviors & weight preoccupation give meaning to one’s life.
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Anorexia Nervosa: Diagnostic Criteria
A. Refusal to maintain a minimally healthy, normal body weight (85% weight criteria)
B. Intense fear of weight gain, despite being underweight
C. Body image distortion & denial of seriousness of condition
D. Amenorrhea for at least 3 consecutive cyclesE. Weight loss is not due to a general medical
condition or the effects of medication
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Anorexia Nervosa: Diagnostic Criteria for Subtypes
Restricting Type: does not engage in binge eating or purging behaviors (e.g. vomiting, use of laxatives, diuretics, enemas)
Binge-Eating/Purging Type: regularly engages in binge-eating or purging behavior
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Anorexia Nervosa: Behavioral Indicators
Restrictive eating Odd food rituals Significant weight loss Preoccupation with food, weight, body size Dressing in baggy clothes or layers Excessive exercising Frequent weighing Denial of hunger Lack of interoceptive awareness
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Anorexia Nervosa: Physical Indicators
Noticeably thin Hormonal imbalances
& menstrual irregularities
Sallow complexion Dry, brittle hair Lanugo Weakness, dizziness,
fainting Muscle atrophy
Premature bone loss Dehydration Low body temperature,
cold intolerance Increased
susceptibility to infections
Low pulse rate, low blood pressure
GI complaints
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Anorexia Nervosa: Psychological Indicators
Body image distortion Perfectionism Obsessive-compulsive traits Mood lability Depression Social withdrawal, isolation Anhedonia Lack of assertiveness People pleasing, care-giving, self-sacrificing
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Anorexia Nervosa: Facts & Figures
Common comorbid psychological disorders: anxiety disorders, depression, OCD, cluster C personality disorders
Gender: 90-95% female Age of onset: mid to late adolescence Prevalence: .5%-1.0% for women; 0.05%-0.1% for men Highest prevalence: adolescence & young adulthood Course: chronic or intermittent; may require hospitalization Prognosis: poor, particularly without treatment Racial & cultural factors: primarily white, but increasing
among other cultures Highest mortality of any mental illness: 10-20%
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Bulimia Nervosa: Diagnostic Criteria
A. Recurrent episodes of binge eating:
1) eating an excessive amount of food
2) feeling out of control during episode
B. Recurrent compensatory behaviors
C. Frequency of at least 2x/week for 3+ months
D. Self evaluation is unduly influenced by body image and weight
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Bulimia Nervosa: Diagnostic Criteria for Subtypes
Purging Type: regularly engages in self-induced vomiting or the use of laxatives, diuretics, or enemas
Nonpurging Type: uses other compensatory behaviors such as fasting or excessive exercise
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Bulimia Nervosa: Behavioral Indicators
Compulsive eating, emotional eating Secretive eating, hiding or hoarding food Visiting bathroom after meals Compensatory behaviors Avoiding social engagements involving food Preoccupation with food, weight, body image
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Bulimia Nervosa: Physical Indicators
Average or above average weight
Frequent weight fluctuations
Swollen glands, puffy cheeks, broken eye blood vessels
Dental erosion Calluses on back of
hands and fingers Ulcers in mouth
Cycling between bloating & dehydration
Sore throat Acid reflux Inflammation of
esophagus Electrolyte imbalances:
depleted potassium, sodium, chloride
GI complaints Irregular heartbeat
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Bulimia Nervosa: Psychological Indicators
Disparaging self for eating too much Usually aware that behavior is abnormal Seeking others’ approval and reassurance Engaging in other self-destructive and
impulsive behaviors Mood lability, irritability High comorbidity with personality disorders
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Bulimia Nervosa: Facts & Figures
Common comorbid psychological disorders: anxiety disorders, mood disorders, substance abuse, cluster C personality disorders (particularly borderline)
Gender: 90-95% female Age of onset: late adolescence to early adulthood Prevalence: 1-3% for women; 0.1-0.3% for men Highest prevalence: adolescence & young adulthood Course: chronic or intermittent Prognosis: poor, particularly without treatment Racial & cultural factors: primarily white, but increasing
among other cultures
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Eating Disorder Not Otherwise Specified: Diagnostic Criteria
• Meets criteria for Anorexia except for body weight or absence of menses
• Meets criteria for Bulimia except for frequency or amount of food consumed
• Chewing and spitting• Meets criteria for Binge Eating Disorder
Eating disorder symptoms that do not meet the criteria for Anorexia or Bulimia:
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Binge Eating Disorder: Research Criteria
A. Recurrent episodes of binge eating: 1) eating an excessive amount of food2) feeling out of control while eating
B. Binge eating episodes are characterized by 3+ of the following:
1) rapid eating2) eating until uncomfortably full3) eating large amounts of food when not hungry4) solitary eating due to embarrassment5) feeling disgust, depression, guilt after eating
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Binge Eating Disorder: Research Criteria
C. Marked distress regarding binge eatingD. Frequency of at least 2 days/week for
6+ monthsE. Does not engage in compensatory
behaviorsF. Eating is not due to a general medical
condition or the effects of medication
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Binge Eating Disorder: Behavioral Indicators
Eating when not hungrySecretive eating, eating little in publicEmotional eating, compulsive eatingConstantly dietingRestricting activities due to
embarrassment about weight and body size
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Binge Eating Disorder: Physical Indicators
Weight gain, weight fluctuations GI complaints Bloating Fatigue High blood pressure High cholesterol Type II Diabetes Heart disease
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Binge Eating Disorder: Psychological Indicators
Feeling out of control over eating Likened to an addiction Mood lability, depression Intense self-hatred/self-criticism Attributes all perceived failures to weight or
body size History of trauma is common
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Binge Eating Disorder: Facts & Figures
Prevalence: 20% of obese people in weight loss program; 50% among candidates for gastric bypass surgery
Prognosis: relatively good Onset: ½ start with dieting and ½ start with
binging Gender: more equally distributed among men
& women
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Eating Disorders: Contributing Factors
History of emotional, physical, sexual abuse History of being teased or ridiculed,
particularly about size or weight Dysfunctional dynamics & relationships with
family & others Difficulty identifying & expressing one’s needs
& feelings Difficulty asserting oneself
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Eating Disorders: Contributing Factors
Control issues Low self-esteem Underlying problems, such as depression,
anxiety, anger, loneliness, insecurity Cultural emphasis on thinness, beauty, &
physical appearance, particularly for women Biochemical or hormonal imbalances Genetic factors
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TREATING EATING DISORDERS
Need for an Integrated, Multidisciplinary Approach
• Psychological Counseling • Nutritional Counseling• Medical Evaluation & Monitoring• Psychiatric Evaluation & Medication Management
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Psychological Counseling
Thorough assessment Individual counseling Involving significant others in treatment Group counseling Therapeutic approach: empathic,
nonjudgmental, relational, functional Empirically validated treatments: Cognitive
Behavioral & Interpersonal
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Nutritional Counseling
Thorough evaluation Psychoeducation Individualized eating and exercise plan Monitoring weight Ongoing support & encouragement
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Medical Care
Comprehensive medical evaluation Monitoring weight and vitals Bloodwork as indicated Education regarding effects of behaviors Ongoing medical stabilization, monitoring, and
support Referral to specialists as indicated Medical clearance for inpatient treatment
programs
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Psychiatric Care
Comprehensive psychiatric evaluation, including diagnostic impressions and treatment recommendations
Medication management: SSRI’s, Wellbutrin, Effexor, Cymbalta, Atypical Antipsychotics, Antianxiety
Need for close collaboration with primary therapist