Tag Archives: anorexia nervosa

Anorexia


Like so many other mental disorders, eating disorders project people who are really “out of balance.”  I don’t think anyone would be an obesity advocate… after all; obesity presents as many or more health problems as being overly thin.  In the end, it’s all about balance.

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1 in 5 women have an eating disorder.  Kids start dieting as early as 4th grade.  I can actually see this, I see a bit of it in my daughter… she is age 8 (2nd grade) and has shown concerns about “being too heavy.”  We have turned the focus onto “being healthy” not “being thin.”  80% of 13 year olds have tried to lose weight… this doesn’t surprise me, considering the “ideal image” that western culture projects to children.  1 in 5 anorexics die?  Our text indicates it was closer to 1-10, that’s nearly double NHW’s estimate.  I know it’s a real problem, but having good epidemiological data would be a good start to “justifying” expending resources to extinguish it.

With regard to what a clinican should know or ask about eating disorders, the following questions are at the top of my list.

1)      Clinicians should know your subtypes of Anorexia Nervosa (AN):

  1. Restricting Type describes presentations in which weight loss is accomomplished primarily through dieting, fasting, or excessive exercise.
  2. Binge-Eating/Purging Type describes presentations where the individual engages in binge eating, purging, or both.  They may employ self induced vomiting, misuse of laxative, diuretics, or enemas.  (American Psychiatric Association, Diagnostic and statistical manual of mental disorders, 2000, p. 585)

2)      Probe for comorbid disorders and associated features, especially depression, anxiety disorders, dissociative disorders, substance abuse, and personality disorders (particularly borderline personality disorder).  (Netherton, Holmes, & Walker, 1999, p. 401)

3)      Clinicians should know that, while these disorders predominantly effect females, males can also suffer from either AN or BN.  “There is some evidence that ED prevalences are recently increasing in males.”  (Blaney & Millon, 2009, p. 433)

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References

American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders (4th ed., text rev.). Washington, DC: Author.

Blaney, P. H., & Millon, T. (2009). Oxford textbook of psychopathology (2nd ed.). New York, New York: Oxford University Press.

Netherton, S. D., Holmes, D., & Walker, C. E. (1999). Child and adolescent psychological disorders: A comprehensive textbook. Oxford, NY: Oxford University Press.

Eating Disorders = BIG BUSINESS


“Weight discrimination and the resulting obsession with thinness are rampant and recalcitrant.  I believe that, in order to make any kind of a dent in this field, we all need to combat these pernicious influences.”  (Netherton, Holmes, & Walker, 1999, p. 412)  Amen.  The weight of the media, the “diet food industry,” and the purveyors of a “healthy lifestyle” propagate this issue… without a doubt.  Losing weight is BIG BUISINESS, and there are huge profits to be made for those that offer obese people the glimmer of a stereotypically thin body.

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I also appreciated the acknowledgement on the pressure exerted by managed care.  Eating disorders appear to be particularly “deep seated” and ill suited for half a dozen one hour sessions.  Correcting inaccurate perceptions, relabeling cognitions of visceral and affective states, and redrawing boundaries… this kind of work takes time… more time than managed care often provides.  This is yet another example of the effect managed care will continue to have for as long as it is the primary method of seeking out psychological assistance.

I was suitably surprised at the long-term mortality rate… suggested to be over 10%.  (Netherton et al., 1999, p. 399)  With a roughly 1 in 10 shot of succumbing to starvation, suicide, or electrolyte imbalance; you would think this particular set of disorders would get more research attention.  The fact that there is still limited epidemiological data is frustrating… perhaps the difficulty obtaining the data is related to the relative secrecy and shame associated with the disorders themselves?

Like the BM text, NHW jumps on the multi-determined etiology bandwagon.  It’s hard to disagree with since biological, familial, sociocultural, and personality factors all seem to be plausible.  The differences in family characteristics were particularly interesting.  “Bulimic families tend to be characterized as disengaged, chaotic, and highly conflictual and as having a high degree of life stress.”  Conversely, “anorexic families tend to be characterized as enmeshed, overprotective, and conflict avoidant.”  (Netherton et al., 1999, p. 400)  That’s a strange clinical picture that seems to suggest that there might be a single underlying biological cause for EDs in general, but that familial and personality factors may play a role in its manifestation.

The list of comorbid disorders we need to consider during the assessment process is long and fairly inclusive.  “Depression, anxiety disorders, dissociative disorders, substance abuse, and personality disorders” are on the forefront of the disorders we should be checking for.  (Netherton et al., 1999, p. 401)  Furthermore, NHW suggest we assess treatment history, as well as suicide attempts and self mutilative behaviors (cutters).

Pharmacological interventions employing antidepressants have been particularly successful.  This text only cites 3 studies that have employed SSRI class antidepressants, but they report “significant improvement with 60-80 mg dosages (of Prozac) compared to placebo.”  (Netherton et al., 1999, p. 407)  I think I am going to dig deep into some more recent research to see of this trend holds up, there has to be more than three studies on it by now.

I like the idea of a behavioral contract… not just for eating disorders, but for any disorders which involve “behavior.”  I am inclined to agree with the statement “the contract provides structure and predictability.  Expectations, rewards, and consequences are delineated so that all people involved (patient, treaters, families) know what is expected at all stages of treatment.”  (Netherton et al., 1999, p. 407)  My question is this… realistically, what “consequences” are there if we are dealing with outpatient treatment?

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Reference

Netherton, S. D., Holmes, D., & Walker, C. E. (1999). Child and adolescent psychological disorders: A comprehensive textbook. Oxford, NY: Oxford University Press.