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Chapter 9

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Konstantine Zakzanis

Ch 9 eating disorders These disorders only appeared in the DSM for the first time in 1980 as one subcategory of disorders beginning in childhood or adolescence Stat Canada 2002, 0.5% of Canadians 15 yrs of age or older reported that they had been diagnosed with an eating disorder in the preceding 12 months. Women were more likely than men to report an E.D ---0.8% vs 0.2% Among young women aged 15-24 1.5% reported that they had an E.D Eating disorders can cause long term psychological, social and health problems Hospitalization is sometimes necessary. Hospitalization rates are highest among young women in the 15-24 age range. Rates are also highest among those ages 10-14 and 20-24 CLINICAL DESCRIPTION The diagnoses of these two disorders share several clinical feautures the most imp being an intense fear of being overweight Co-twins of patients diagnoses with A.N for ex are themselves more likely than average to have B.N Anorexia Nervosa Ms. A had A.N. anorexia refers to loss of appetite and nervosa indicates that this is for emotional reasons Most patients with A.N actually do not lose their appetite or interest in food. They are preoccupied with food Ms. A met all the four features required for the diagnosis: 1) the person must refuse to maintain a normal body weight, that is usually taken to mean that the person weights less than 85% of what is considered normal for that persons age and height. Weight loss is typically achieved through dieting although purging (self induced vomiting, heavy use of laxatives or diuretics) and excessive exercise can also be part of the picture 2) the person has an intense fear of gaining weight and the fear is not reduced by weight loss. They can never be thin enough 3) Patients with AN have a distorted sense of their body shape. They maintain that even when emaciated they are overweight or that certain parts of their bodies esp the stomach, butt and thighs are too fat. To check on their body size they typically weight themselves frequently, measure the size of diff parts of the body and gaze critically at their reflections in the mirror. Their self esteem is closely linked to maintaining thinness. The tendency to link self esteem and self evaluation with thinness is known as over evaluation of appearance 4) in females the extreme emaciation causes amenorrhoea the loss of the menstrual period. Of the four diagnostic criteria amenorrhoea seems least imp to determining a diagnosis of anorexia. Moreover amenorrhoea occurs in a significantly minority of women before any significant weight lose and the symptoms can persist after weight gain eating disorder inventory (EDI). Was developed in Canada and is one of the most widely used measured to assess self reported aspects of eating disorders patients with AN overestimate their own body size and choose a thing figure as their ideal DSM-IV-TR distinguishes two types of AN. In the restrictive type, weight loss is achieved by severely limiting food intake; in the binge eating purging type the person also regularly engages in binge eating and purging The binging purging subtype appears to be more psychopathological; patients exhibit more personality dis, impulsive beh, stealing, alcohol and drug abuse, social withdrawal and suicide attempts than do patients with the restricting type of anorexia Binging purging patients tend to weight more in childhood, come from heavier families with greater familial obesity and use more extreme weight control methods. Canadian research suggests that the diff between the two subtypes are becoming less distinct An increasing proportion of patients were diagnosed with AN, the binging purging subtype, during each period. Over time, participants in both groups appeared to weigh more and were less likely to report amenorrhoea. Patients from both groups reported higher frequencies of purging beh, impulsive beh, and associated affective symptoms in the later time periods AN typically begins in early to middle teenage years often after an episode of dieting and exposure to life stress. It is about 3-10 x more frequent in women than in men with a lifetime prevalence about 1% in women When AN does occur in men, symptomatology and other characteristics, such as family conflict, are generally similar to those reported by women with the disorder Found that males had lower levels of drive for thinness and body dissatisfaction but there were many more similarities than differences between the males and females Patients with AN are diagnosed frequently with depression, OCD, phobias, panic disorder, alcoholism, oppositional defiant disorder, and various personality disorders Comborbidty is higher in clinical samples than community samples. A growing concern is the high rate of occurring eating disorders and substance use disorders Physical Changes In AN Blood pressure often falls, heart rate slows, kidney and gastrointestinal problems develop, bone mass declines, the skin dries out, nails become brittle, hormone levels change and mild anemia may occur Some patients lose hair from the scalp, and they may develop laguna, a fine, soft hair on their bodies. Levels of electrolytes such as potassium and sodium are altered. These ionized salts present in various bodily fluids are essential for the process of neural transmission and lowered levels can lead to tiredness, weakness, cardiac arrhythmias and even sudden death. Brain size declines in patients with anorexia and EED abnormalities and neurological impairments are frequent Deficits in white matter volumes in the brain are restored upon recovery from anorexia nervosa but deficits in grey matter volumes appear irreversible at least in the short term. These consequences may be especially problematic for adolescents with AN Prognosis About 70% of patients with AN eventually recover. However recovery often takes 6 or 7 years and relapses are common before a stable pattern of eating and maintenance of weight is achieved. AN is a life threatening illness, death rates are about 10 x higher among patients with the disorder than among the general population and twice as high as among patients with other psychological disorders Death most often results from physical complications of the illness or from suicide The standardized mortality rate for the 326 patients with AN was very high (10.5). standardized mortality rate is defined as the ratio of observed deaths relative to expected deaths. Among the 17 AN patients who had died the leading cause was suicide followed by pneumonia, hypoglycemia and live disease Found that suicide rates are not elevated in B.N like they are in AN though ppl with BN are more likely to have suicide ideation. Predictors of suicide in AN patients include purging beh, depression, substance abuse and a history of physical or sexual abuse Bulimia Nervosa Ms Bs beh is BN. Bulimia from a Greek word means ox hunger. This disorder involves episodes of rapid consumption of a large amount of food, followed by compensatory beh such as vomiting, fasting or excessive exercise to prevent weight gain The DSM defines a binge as eating an excessive amount of food within less than two hours. BN is not diagnosed if the binging and purging occur only in the context of AN and its extreme weight loss; the diagnosis in such as case is AN binge eating purging subtype Binges typically occur in secret may be triggered by stress and the negative emotions it arouses and continue until the person is uncomfortably full. Stressors that involve negative social interactions may be particularly potent elicitors of binges. Bulimics have high levels of interpersonal sensitivity, as reflected in large increases in self- criticism following negative social interactions. Further binge episodes tend to be preceded by poorer than average social experiences, self concepts and moods Also reported that the binge episodes are followed by deterioration in self concept, mood state and social perception The person who is engaged in a binge often feels a loss of control over the amount of food being consumed. Foods that can be rapidly consumed, esp sweets such as ice cream or cake are usually part of a binge. Although research suggests that patients with BN sometimes ingest an enormous quantity of food during a binge. Binges are not always as large as the DSM implies and there may be wide variation in the caloric content consumed by individuals with BN during binges. Patients are usually ashamed of their binges and try to conceal them. They report that they lose control during a binge even to the point of experiencing something akin to a dissociative state perhaps losing awareness of what they are doing of feeling that it is not really they who are binging After the binge is over disgust, feelings of discomfort and fear of weight gain lead to the 2 step of BN[urging to undo the caloric effects of the binge. As seen with Ms. B purging can involve induced vomiting and excessive exercise. The use of laxatives and diuretics is common even though this odes not actually result in weight loss
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