Week 9: Eating and Feeding Disorders

What is the history feeding and eating disorders?

They have been recognized throughout history. Each historical period has influenced the frequency and appearance of these disorders. The causes of bulimia have been described of thousands of years. Societal, cultural, or religious beliefs have always affected people’s eating patterns. During the Dark Ages, a person could rid themselves of sin and/or sexual desire through acts of purging. During the Middle Ages, women known as “the sainted women” starved themselves for religious beliefs. These episodes of starvation as referred to as anorexia mirabilis or holy anorexia. Anorexia nervosa was first described in the early 1860s and 1870s by the French physicians Marce and Lesegue and by English physician Sir William Gull

What are risk factors for eating disorders?

Various factors can play a role in an individual’s judgments about their body, such as cognitive, affective, cultural, and attitudinal. Being overweight, dieting and dissatisfaction with one’s body, and status in a higher social class seem to be increasingly recognized as the primary risk factors for developing an eating disorder. Eating disorders are typically first noticed during late childhood and early adolescence, they often continue well into adulthood. None of the disorders appear to be specific to a certain culture. Anorexia and bulimia have been found in several immigrant populations. However, they seem to be more prominent in Western countries including the U.S. in contrast to countries where food is scarce.

What are the DSM eating and feeding disorders?

(8) Pica 307.52 (F98.3 in children & F50.8 in adults), Rumination Disorder 307.58 (F98.21), Avoidant/Restrictive Food Intake Disorder 307.59 (F50.8), Anorexia Nervosa 307.1 (F50.01 Restrictive type and F50.02, Binge-eating/purging type), Bulimia Nervosa 307.51 (F50.2), Binge-Eating Disorder 307.51 (F50.8), Other Specified Feeing or Eating Disorder 307.59 (F50.8), Unspecified Feeding or Eating Disorder 307.50 (F50.9)

What is Pica 307.52 (F98.3 in children and F50.8 in adults)?

It is not unusual for children to put things into their mouths. People with the diagnosis of this go far beyond this exploration. It is is characterized by a person’ appetite for substances that are largely nonnutritive/nonfood substances. The most commonly ingested substance is ice.

What are some of the nonfood items people with pica frequently crave?

Dirt, Clay, Paint Chips, Plaster, Chalk, Cornstarch, Laundry starch, Baking soda, Coffee grounds, Cigarette ashes, Feces, Ice, Glue, Hair, Buttons, Paper, Sand, Toothpaste, Soap, Burnt match heads, Cigarette Butts. Need to be concerned with lead levels in the person’s blood, intestinal blockages, lack of iron, etc.

What is the Pica Prevailing Pattern?

Difficult to establish. People are reluctant to admit to abnormal cravings and ingesting nonnutritive substances. More commonly seen in women and children affecting all ages. Also commonly seen in individuals with neurodevelopmental disorders.

What is the Pica Differential Assessment?

typically defined as the persistent ingestion of nonnutritive substances for a period of at least 1 month - occurs at an age where the behavior is not developmentally inappropriate. It is not considered to be part of a culturally sanctioned practice (Kaolin ingestion is a widespread practice in parts of Africa - seems to stem from health benefits such as the abiltiy of clay to absorb plant toxins and protect against toxic alkaloids and tannic acids). It is helpful to conduct various tests for iron and zinc – (We may see bowel obstructions or an intestinal obstruction Bezoar (a had, indigestible mass trapped in the GI system), intestinal perforations, or infections resulting from ingesting feces or dirt, or poisoning from ingesting certain substances, for instance lead paint.

When will the practitioner may add the specifier “in remission” for pica?

if criteria have been present but currently not met for a sustained period of time.

What is Rumination Disorder 307.58 (F98.21)?

It is a problem that occurs when someone repeatedly regurgitates their food and then may re-chew, re-swallow, or spit it out. Typically affects newborns, infants, children, and individuals with mental and functional disabilities. Occurs in males and females of all ages and cognitive abilities. Once thought of as rare, has since been regarded as not particularly rare, but rather as rarely recognized. Likely comes to the attention of a pediatricion more than a social worker.

What is Rumination Disorder Prevailing Pattern?

Exact prevalence rates are unknown. Most individuals with the disorder are very private about their illness. The disorder is higher in people with intellectual disabilities. The typical age of onset is from 3 to 12 months of age, while adolescent onset is at about 12 years of age.

What is Rumination Disorder Differential Assessment?

Involves the repetitive regurgitation of undigested food (or rumination) from the stomach back up into the mouth. Usually occurs 1 to 2 hours after most meals for at least 1 month. It is considered chronic in that regurgitation typically happens after every meal.

What do we need to rule out when diagnosing rumination disorder?

We must rule out gastroesophageal reflux disease (GERD) or pyloric stenosis (a problem with a baby’s stomach that causes forceful vomiting). We also must rule out anorexia nervosa, bulimia nervosa, binge-eating disorder, or avoidant/restrictive intake food disorder. The social worker can also add the specifier “in remission.”

What is Avoidant/Restrictive Food Intake Disorder 307.59 (F50.8)?

This is an eating disorder that prevents the consumption of certain foods. The child is severely harmed due to selective or restrictive eating habits. It may be that the child experienced a choking incident or might have gotten the stomach flu the last time they tried to eat. In other situations, the person tends to avoid eating in public, at work, with friends, or with family.

What is ARFID Prevailing Pattern?

Individuals with this are more likely to be male, picky eaters since early childhood, experience GI symptoms, have a history of vomiting/choking and have food allergies.

What is ARFID Differential Assessment?

The first critical element is feeding or eating disturbances, which may include but are not limited to: (The decreased interest toward food or eating in general, Avoidance, which is associated with the sensory characteristics of food, Increased concern toward the various consequences or disadvantages of eating, manifested by repeated failure or inability to meet the ideal energy and nutritional requirement and needs). The practitioner can further specify the dx of ARFID as in remission when the criteria have previously been met but have not currently been met for a sustained period of time. The course of the illness is not known. Often, we will see a childhood encounter food that is revolting. The child may later exclude whole food groups from their diets. Others may exclude foods based on color, temperature, and/or texture

What would we expect to see in AFRID?

Considerable amount of weight loss, Presence of different nutritional deficiencies in the person from bloodwork, Enteral feeding dependency (tube feeding) or oral nutritional supplements, Interference or disturbance of psychosocial functioning. The practitioner can further specify the dx of this as in remission when the criteria have been previously met but have not currently been met for a sustained period of time.

What other disorder can be risk factors for AFRID?

Anxiety disorders - panic about reliving an early incident like choking on a chicken bone, OCD - obsessive thoughts about certain foods, Neurodevelopmental disorder - perhaps neurologically determined, ADHD - inbility to focus on eating anything requiring particular effort - fish with a lot of bones, ASD - frequently associated with a perseveration on certain foods, Intellectual disability - fear of certain foods, MDD - part of the somatic component of the disorder - weight loss, Schizophrenia - “my food is being poisoned”, Factitious disorder - for all the reasons you can already imagine

What is anorexia nervosa?

The most striking feature is the marked distortion in the way the individuals experience their body size and shape. Often they have no concept of how they appear to others. They are generally dissatisfied with their weight. Losing weight every day and for months is seen as satisfactory. Although the person is usually hungry and preoccupied with thoughts of food, they will not eat because of their relentless obsession to be thinner.

What motivates eating disorder?

In general, peer pressure, media influence, and the perception that extreme dieting strategies are harmless. They may push a person to want to be thinner and more beautiful. If it pushes them to anorexia is highly debated.

What would we see in anorexia?

We would see individuals weigh between 25% - 30% below their normal weight. The difference between someone who is of low weight and someone with this revolves around intrapersonal factors, whereby the individual refuses to maintain a normal body weight and is extremely fearful of becoming fat. Biological issues should be explored: (Taking laxatives, Excessive exercise, Dieting, nutritional patterns - foods that don’t stay in the body long, are full of roughage like vegetables).

Do most individuals with eating disorders exhibit a prodromal phase?

No, they do not. A person goes from a healthy eating pattern right into anorexia. A major life cycle can set it off - going to college, death of a loved one.

What will immediately precede the onset of anorexia nervosa?

Occasionally, going off to college, experiencing a death in the family, or some other major life cycle event.

What is the key is that individuals with AN?

They have two faulty perceptions regarding their own body: They way they view their body-or body image distortion, and body image concerns involving a delusional misperception, referred to as “body dysmorphophobia.”

What are Anorexia Nervosa Questions to ask?

Have people ever given you a hard time about being too thin or losing too much weight? Have you ever weighed a lot less than others thought you should weigh? If yes, follow with: How old were you when this first happened? Is this still true? What was the lowest amount you have ever weighed as an adult? What do you weigh right now? How do you feel about that? What do you think about you body size and shape? What do you think about how much you weight? Are you on a diet right now? Do you ever feel the urge to binge and purge? What happens when you do? How often do you diet? Have either you or anyone in your family ever had a history of anorexia, bulimia, binge-eating, or obesity?

What is the Anorexia Nervosa Prevailing Pattern?

The 12-month prevalence rates in young females is approximately 0.4%. The disorder is more common in females. The female-to-male ratio is 10:1. We know relatively less about why the rates are so low in men.

What is the Anorexia Nervosa Differential Assessment?

Two subtypes: restricting type and binge eating/purging type

What is Restricting type?

The individual severely limits caloric intake (for at least the past 3 months), but does not regularly engage in binge eating or purging behaviors. They are highly controlled, rigid, and obsessive. The person might eat very slowly, make food less attractive, or garnish food with unappetizing spices. They can also be found to diet, fast, and/or excessively exercise to lose weight.

What is Binge eating/purging type?

These individuals regularly engage in weight control behaviors such as self-induced vomiting and/or misuse of laxatives, enemas, or diuretics. The person alternates between periods of perfectionism (with rigid control) and impulsive binge-eating behavior. A binge is eating a much larger amount of food than most people would eat under similar circumstances in a limited period of time. Bulimia is a different dynamic. Here, the person sees themselves as very overweight.

What is binging in AN?

Some binges occur in time-limited situations, such as over the lunch hour; while others can take up most of the day. The individual can also eat small amounts of food continuously – known as grazing. Binge episodes should be distinguished from those overeating incidents that occur during special occasions such as birthday celebrations or holiday events. Binge eating is often followed by depressive moods, feelings of guilt, and self-deprecating thoughts. The social worker should describe if the current symptom picture rather than overall progression.

What is purging?

is defined as any activity aimed at ameliorating the perceived negative effects of a binge or body shape and weight. This includes self-induced (vomiting); the misuse of laxatives, enemas, or diuretics, and/or excessive exercise. When exercise and diet are used for weight loss rather than to counteract the effects of a particular episode or excessive bingeing, they should be regarded as compensatory behaviors.

Can individuals cross over between the two subtypes in AN?

Yes, over the longer term of the illness. The social worker should describe the current symptom picture rather than overall progression. People with this are often not very forthcoming.

What is specifier partial remission for AN?

when full criteria for the diagnosis have previously been met, but at this point in time, low body weight has not been met for a prolonged period.

What is the specifier “in full remission” for AN?

assigned when none of the diagnostic criteria have been met for an extended period of time.

How else is severity calculated in AN?

by body mass index (BMI) and specified mild, moderate, severe, or extreme. BMI is an outdated measure. Concerned with low BMI - Osteoporosis Constipation, Swollen joints.

What is a mild BMI in AN?

BMI greater than or equal to 17 kg/m

What is moderate BMI in AN?

BMI 16 to 16.99 kg/m.

What is severe BMI in AN?

BMI 15 to 15.99 kg/m.

What is extreme BMI in AN?

BMI less than 15 kg/m.

How do you calculate BMI?

divide your weight in kilograms (kg) by your height in meters (m). Then divide the answer by your height again to get your BMI. Example: A 20-year-old woman who is 5’7” weighs 140 LBS. Her BMI would be 21.9, which is considered with the healthy range. If she restricts her food intake and loses roughly 22% of her body weight, or 31 lbs, she would weigh 109 lbs. Her BMI would be 17.1, which is in the range of “mild.”

What can purging cause?

cardiovascular or renal problems including: (Hypotension, Bradycardia (slow heartbeat), Cardiac arrhythmia, Risk of kidney failure - Decreased potassium, sodium, magnesium, phosphate, and chloride leading to hypokalemic alkalosis (a kidney condition resulting from extreme lack or loss of potassium). It can also cause fatigue and weakness, seizures, and cognitive disorders, infected salivary glands, loss of dental enamel

What are Anorexia Nervosa Rule/outs?

Other reasons for weight loss including: Hyperthyroidism, HIV/AIDS, Crohn’s disease, Neoplams: Abnormal skin growths, TB, In Schizophrenia: people are not preoccupied with the fear of becoming fat, nor do they perceive body distortions. Those with MDD may eat very little and profess to have little or no appetite. However, peculiar attitudes about eating are absent. Those with social anxiety disorder may feel embarrassed when seen eating in public but they are not preoccupied with weight or body distortion.

What is the Anorexia nervosa illness course?

The course varies; some individuals recover after a single episode, whereas others continue to vacillate between trying to restore their normal weight and/or relapsing. It is considered a potentially fatal disease, with a mortality rate somewhere between 5 and 10 percent. The mortality rate from eating disorders, and particularly anorexia, is the highest of any psychological disorder. The cause of death is usually associated with starvation, suicide, infection, or electrolyte imbalance.

Practitioners may detect the following signs of AN?

Dry, yellowish, or scaly textured skin. Lanugo (peach fuzz or baby fine hair found on the trunk, face, and extremities). Intolerance to cold temperatures or hypothermia. Extensive weight loss that has affected the skeletal structure. Dull, lifeless hair, a pale complexion, poor posture, and extreme thinness.

What is Bulimia Nervosa 307.51 (F50.2)?

Characterized by repeated dietary restriction alternating with uncontrollable binge eating and desperate measures to prevent weight gain. To counteract the effects of eating, the person will either vomit or use compensatory methods (e.g., using large amounts of laxatives to purge their bowels) to control their weight. Fasting though typically backfires. The person eats larger amounts of food (often junk food) than most people would or could eat under similar circumstances. There is some overlap with AN. Many people with this have a history of AN. Evaluate how often the individual engages in the purging/bingeing behaviors.

Bulimia Nervosa Prevailing pattern?

Typically young female. The 12-month prevalence is from 1 to 1.5 percent. We know less about the prevalence among males, but may be about 10% of that found in females.

What is the Bulimia Nervosa: Differential Assessment?

The person generally has normal weight or slightly above-normal weight. They exhibit a pattern of sequential binge eating in addition to inappropriate compensatory weight loss responses that include self-induced purging, misuse of laxatives or enemas, and excessive exercise. The majority of eating disorders are first noticed during late childhood and early adolescence, they often continue well into adulthood. The person with bulimia does not have the extreme distortion of self-image seen in AN. However, the person with BN, like the person with AN is extremely fearful of being fat.

What are Bulimia Nervosa Symptoms?

Recurrent episodes of binge eating. Eating occurs during a discrete period of time, the amount of food consumed is larger than most other individuals would eat during a similar period of time and under similar circumstances. The individual experiences a lack of control over eating during the episode; they cannot stop eating or control what they are eating. Recurrent, inappropriate compensatory methods are used to prevent weight gain. Both the binge eating and inappropriate compensatory methods occur, on average, at least once a week for 3 months. Body shape and weight unduly influence the way a person sees themselves. The disturbance does not occur exclusively during episodes of AN.

What are Bulimia Nervosa Specifiers?

Partial remission, full remission. Current severity is also considered and calculated by the number of inappropriate compensatory behaviors per week and specified as mild, moderate, severe, or extreme.

What is partial remission in BN?

when full criteria have previously been met, but at this point some, but not all, of the criteria have been met for a sustained period of time.

What is full remission in BN?

assigned when none of the diagnostic criteria have been met for an extended period of time.

What is mild in BN?

an average of 1 to 3 episodes per week.

What is moderate in BN?

an average of 4 to 7 episodes per week.

What is severe in BN?

an average of 8 to 13 episodes per week.

What is extreme in BN?

an average of 14 or more episodes per week.

What are Bulimia Nervosa Co-occurring disorders?

Depressive disorders due to the low self-esteem related to binge eating, a feeling of a lack of control, and the use of compensatory behaviors to prevent weight gain. Bipolar disorder is sometimes diagnosed. Anxiety or an anxiety disorder - The person may also be worried about eating in social situations. Substance-related disorders may appear due to worry about appetite control (about 30% of people with bulimia will develop a substance-use disorder).

What is the Bulimia Nervosa Symptom onset?

The onset occurs relatively innocuously during adolescence or the early 20s. Purging may serve as a convenient method of overeating without gaining the resulting weight, but then becomes a destructive process. We would likely see impaired interpersonal relationships, which leads to isolation, shame, helplessness, and lowered self-esteem. The illness would be both chronic and episodic (There may be a gradual or acute presentation. Individuals may be able to sense a binge eating episode, at other times there may be nor forewarning. They may or may not report feeling hungry preceding a binge. The binge may be precipitated by the simple presence of something to eat. High calorie sweets are the food of choice and food that are easy to regurgitate. The binge can last upwards to an hour – long past the point of being full).

What are bulimia nervosa symptoms?

The person often feels helpless, disgusted, depressed, and fearful about becoming fat. The person usually feels very guilty and anxious about the amount of food consumed and the planning to get rid of it begins almost immediately. The most common action is vomiting. Some individuals can vomit at will. The person tends to be very secretive and the behaviors.

What are Bulimia Nervosa Signs to look for?

Russell’s Signs: Skin lesions, abrasions, small lacerations, or raised calluses on the top surface of fingers and knuckles. Sometimes people use ipecac or diuretics. Other approaches include laxatives, enemas or even coat hangers, waded paper, or pens that are stuck down the throat. Vomiting can lead to serious heart damage. Excessive laxative abuse causes permanent damage to the colon. Electrolyte imbalance causes irregular heart beats and kidney failure and is the most severe medical complication associated with this. Impulsive behaviors such as shoplifting, substance abuse. Personality disorders such as borderline and avoidant. Child abuse victims are more likely to have an eating d/o as they get older.

What are Russell’s Signs?

Skin lesions, abrasions, small lacerations, or raised calluses on the top surface of fingers and knuckles.

What is Binge-Eating Disorder, 307.51 (F50.8)?

The most common ED in adults in the U.S. An increase in the variety of foods can lead to increase in consumption. Food cues are activated in the same part of the brain as those who are addicted to ATOD – particularly foods that are higher in sugar, fat, and salt. Binge-Eating Disorder is the most common eating disorder among adults in the US. The disorder most closely resembles bulimia, except that there is no self-induced compensatory behaviors. We see recurrent binge eating, but without subsequent purging episodes.

What is Binge-Eating Disorder Prevailing pattern?

1.6% in adult females and .8% in adult males and about 1.6% in adolescents. The lifetime prevalence is about 3.5% for women and 2% for men. More prevalent among those seeking weigh-loss treatment than in the general population.

What is Binge-Eating Disorder Differential assessment?

People with BED often report disorganized even chaotic eating habits. Anywhere from 5,000 to 15,000 calories are consumed within a binge. Most people who binge feel ashamed and try to hid their problem. Although dieting is related to binge eating, it is not clear if dieting causes the disorder. For some, skipping a meal, not eating enough food each day, or avoiding certain kinds of foods may lead to binge eating. BED leads to obesity (which is a separate disorder, but not a disorder in the DSM!!!!!!!!!!!!!!!!!!)

What are Binge-Eating Disorder Symptoms?

Binges consist of eating, in a discrete period of time an amount of food larger than most people would eat in a similar period accompanied by a feeling of loss of control. Also, the person must have three or more of the following: (Eats more quickly during binge episodes than during normal eating episodes. Eats until physically uncomfortable and nauseated due to the amount of food consumed. Eats large amount of food even when not hungry. Often eats alone during periods of normal eating, owing to feelings of embarrassment about food. Feels disgusted, depressed, or guilty about binge eating or very guilty afterward. Bingeing at least 1 time per week for 3 months without accompanying compensatory behaviors.

Binge-Eating Disorder Other thoughts?

No one knows for sure what causes BED or about its development. Genetic inheritance may be a factor. There is a higher incidence of co-occurring MDD, anxiety disorder, bipolar disorders, and substance use disorder. There may also be body dysmorphic disorder. 78.9% of people with BED have a co-occurring psychiatric disorder - people may come to you for another psychiatric disorder. There is some question that people with BED never learned how to deal with stress, and instead found comfort in eating.

What are Other Specified Feeding or Eating Disorder, 307.59 (F50.8)?

This diagnosis is used when the person shows symptoms of an eating and feeding disorder, and experiences distress or impairment, but does not meet full criteria for any of the other disorders. The social worker should indicate the specific reason that the client does not meet criteria, such as: (Atypical anorexia nervosa: overall weight is within normal range. Bulimia nervosa: people do not meet the required time criterion; that is less than once a week and/or for less than 3 months. Binge-eating disorder used when all criteria for binge-eating disorder have been met except the required time criterion is not met. Purging disorder: The individual engages in recurrent purging/self-induced vomiting behavior to effect weight or shape in the absence of binge eating).

What is Unspecified Feeding or Eating Disorder 307.50 (F50.9)?

What is the role of obesity?

While not physically healthy, obesity is not considered a psychiatric disorder yet. However, it is generally lumped together with eating or weight disorders. Unfortunately, this only serves to stigmatize those who are heavy. The prevalence of obesity or BMI of 30 or greater among adults of all gender, age, and racial/ethnic groups in the US was 30.5% in 2000, and then up to 33.8% in 2008 of the general population. 5.7% of the adult population has a BMI over 40, or 10 million people in the US. We have not established a consistent association between obesity and psychological or behavioral syndrome. Consequently, obesity is NOT considered an eating disorder in the DSM! - If the prevalence of the disorder is nearing 50%, will it be considered a psychiatric disorder or will it be considered normal?