Assessing & Treating Eating Disorders

Kayj Nash Okine, Ph.D.

Chrysalis Center for Counseling & Eating Disorder Treatment

The Continuum Model of Eating Disorders

NORMAL EATING

WEIGHT PREOCCUPATION

CHRONIC DIETING

BINGE EATING

PURGING

SUBCLINICAL EATING DISORDER

CLINICAL EATING DISORDER

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.

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

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

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

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

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

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%

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

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

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

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

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

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

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:

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

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

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

Binge Eating Disorder: Physical Indicators

Weight gain, weight fluctuations GI complaints Bloating Fatigue High blood pressure High cholesterol Type II Diabetes Heart disease

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

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

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

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

TREATING EATING DISORDERS

Need for an Integrated, Multidisciplinary Approach

• Psychological Counseling • Nutritional Counseling• Medical Evaluation & Monitoring• Psychiatric Evaluation & Medication Management

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

Nutritional Counseling

Thorough evaluation Psychoeducation Individualized eating and exercise plan Monitoring weight Ongoing support & encouragement

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

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