Class 6- Partnering with persons experiencing eating, personality disorders, and autism/ADHD

Eating disorders

• Approx 5% of the population will experience an eating disorder at one point in their lives 

• Eating disorders are behavioural conditions characterized by severe and persistent disturbance in eating behaviors and associated distressing thoughts and emotions 

Types of eating disorders (DSM-5,2013)

• Anorexia nervosa

• Bulimia nervosa 

• Binge eating disorder

• Avoidant restrictive food intake disorder

Biologic risk factors for eating disorders

• Dieting 

• Metabolic rate

Social risk factors for eating disorders

• Ideals of beauty 

• Media 

• Fashion

• Cultural

Psychological risk factors for eating disorders

• Low self-esteem 

• Body dissatisfaction 

• ineffectiveness/lack of assertiveness

Spiritual risk factors for eating disorders

• Sense of well-being 

• Quality of life 

• Attitudes

Unrestricted eating (Continuum of eating Experience

• Healthy eating , exercises, weight, and body image 

• Eating and appearance not an issue 

• May include binge eating 

Watchful eating (Continuum of eating Experience)

• Identifies self as a dieter, body sculptor 

• Attends to food composition and calories 

• Begins calorie counting, tracking exercise 

• Modifies daily caloric, fat, and carbohydrate consumption 

• Exercises and/or weight trains to change body 

Increasing weight and shape preoccupation (Continuum of eating Experience)

• More rigidly adheres to food selection and eating patterns 

• Insistent calorie counting, preoccupation with food composition and exercise 

• Tracks weight loss and gains 

• Patterns of yo-yo dieting may emerge with overeating as a response to dietary restriction 

• Ingests chemical preparations and supplements to target appearance ideals 

• restricts/avoids food intake, binge eating and purging may increase frequency and/or duration 

Clinical eating disorders (Continuum of eating Experience)

• Anorexia nervosa 

• Binge-eating disorder

• bulimia nervosa

• Other specified feeding or eating disorder (DSM-5)

Continuum of eating experience

• Unrestricted eating

• Watchful eating

• Increasing weight and shape preoccupation

• clinical eating disorders

Binge eating

• Rapid, episodic, impulsive, and uncontrollable ingestion of large amount of food over a short period of time (1 to 2 hours) 

• Eating followed by guilt, remorse, and severe dieting 

Dietary restraint

• Restricting intake is believed to explain the relationship between dieting and binge behaviour 

• Restraining intake is predictive of overeating

Anorexia Nervosa: Diagnostic Criteria (DSM-5,2013) 

• Restriction of energy intake relative to requirements leading to a significantly low body weight 

• Intense fears of gaining weight or of becoming fat or persistent behaviour that interferes with weight gain even though at a significantly low weight 

• Disturbance in the way in which one’s body weight or shape is experienced undue influence of body weight, shape on self-evaluation or persistent lack of recognition of the seriousness of current low body weight 

Mild Anorexia Nervosa (Assessing severity) 

• BMI more than 17

Moderate Anorexia Nervosa (Assessing severity)

BMI 16-16.99

Severe Anorexia Nervosa (Assessing severity)

BMI 15-15.99

Extreme Anorexia Nervosa (Assessing severity)

BMI less than 15

Anorexia Nervosa (DSM-5, 2013)

• Onset in adolescence or early adulthood. 0.3% to 1% prevalence; female-to-male ratio 10:1

• Chronic condition with relapses characterized by significant weight loss 

• Higher all-cause mortality than other psychiatric disorders with the exception of substance use and postpartum admission 

Biologic (Anorexia Nervosa: Bio/Psychosocial Aetiologies(causes)

• Increased genetic vulnerability 

• Dieting →starving 

• Overexercisingma 

• Decreased awareness of hunger 

• OCD

• Decreased serotonin activity 

Social Anorexia Nervosa: Bio/Psychosocial Aetiologies(causes) 

• Idealization of thinness-media

• Pursuit of thinness

• Enmeshment with family 

• Overprotective family 

Psychological Anorexia Nervosa: Bio/Psychosocial Aetiologies(causes) 

• separation -individualization struggle 

• Sexually conflicts 

• Decreased awareness of emotional cue 

• Feminist view → role pressures 

• Negative body image -body dissatisfaction 

Spiritual  Anorexia Nervosa: Bio/Psychosocial Aetiologies(causes) 

• Spiritual distress 

Social expectations (Anorexia nervosa: social theories)

• Societal norms and expectations 

• Media, fashion industry, peer pressure 

• Body dissatisfaction is related to low self-esteem, depression, dieting, binging, and purging

Family responses (Anorexia nervosa: social theories)

• Enmeshment 

• Over protectiveness

Spiritual (Anorexia nervosa: social theories)

• Core struggles in eating disorders are spiritual in nature 

• Individuals tend to lose the ability to affirm their self-worth and identity 

• Feeling distant and disconnected from family and friends

Goals (interdisciplinary treatment)

• Initiating nutritional rehabilitation 

• Resolving conflicts around body image disturbance 

• Increasing effective coping 

• Addressing underlying conflicts 

• Assisting family with healthy functioning and communication 

Treatment modalities (interdisciplinary treatment) 

• Hospitalization necessary if health deteriorates 

• Interdisciplinary approach 

• Pharmacologic approaches

Diagnostic criteria: Bulimia Nervosa (DSM-5,2013) 

• Recurrent episodes of binge eating 

• A sense of lack of control over eating during the episode 

• Recurrent compensatory behaviours to prevent weight gain including self-induced vomiting, misuse of laxative, diuretics or other medications, fasting, excessive exercising 

• Binge eating and compensatory behaviours occur at least once a week for three months 

• Self-evaluation is unduly influenced by body shape and weight 

Mild (Bulimia nervosa: assessing severity)

• 1-3 episodes of compensatory behaviours/week

Moderate (Bulimia nervosa: assessing severity)

4-7 episodes of compensatory behaviours/week

Severe (Bulimia nervosa: assessing severity)

• 8-13 episodes of compensatory behaviours/week 

Extreme (Bulimia nervosa: assessing severity) 

• 14+ episodes of compensatory behaviours/week 

Bulimia nervosa

• Approximately 1-3% of young women develop BN in their lifetime 

• Onset is in adolescence or early adulthood (older than anorexia nervosa) 

• In the community setting, 1case in 4 of BN is a male 

• Often related to western culture social values 

• First-degree relatives more likely to develop 

• Comorbid conditions include substance abuse and anxiety disorders 

How bulimia presents its self

• Recurrent episodes of binge eating 

• Does not come to the attention of parents and peers as quickly as AN 

• Binge and purge in secret 

• Usually normal weight 

Clinical course (bulimia nervosa)

• Few outward signs 

• Treatment often delayed for years

• Treatment initiated when control of eating is lost 

• Recovery after treatment initiation 

Interdisciplinary treatment (Bulimia nervosa) 

Usually takes place in an outpatient setting 

Focuses on psychological issues including: 

• Boundary setting and separation-individuation conflicts 

• Changing problematic behaviours and dysfunctional thought patterns and attitudes

• Spiritual component 

Binge-eating disorder

• Ingestion of a large amount of food in a short period of time 

• Sense of loss of control during the binge 

• Distress regarding the binge 

• Eating until uncomfortably full 

• Feelings of guilt or depression following the binge 

• Purging does not occur with BED 

Diagnostic criteria: binge eating disorder 

• Recurrent episodes of binge eating that occur on average at least once a week for a period of 3 months 

• Influenced by such cues as dietary restraint, hunger, and negative affective states 

Avoidant-Restrictive food intake disorder (ARFID) 

• An eating or feeding disturbance (e.g. apparent lack of interest in eating or food; avoidance based on the sensory characteristics of food; concern about aversive consequences of eating)

• Is not better explained by lack of available food or by associated cultural sanctions practice 

• Does not occur exclusively during the course of anorexia nervosa or bulimia nervosa, and there is no evidence of a disturbance in the way in which one’s body weight or shape is experienced 

• Is not attributable to a concurrent medical condition or not better explained by another mental disorder. When the eating disturbance occurs in the context of another condition or disorder, the severity of the eating disturbance exceeds that routinely associated with the condition or disorder and warrants additional clinical attention 

Diagnostic criteria: Avoidant-Restrictive food intake disorder (ARFID)

An eating or feeding disturbance (e.g. apparent lack of interest in eating or food; avoidance based on the sensory characteristics of food; concern about aversive consequences of eating) as manifested by persistent failure to meet appropriate nutritional and/or energy needs associated with one (or more) of the following: 

• Significant weight loss (or failure to achieve expected weight or faltering growth in children)

• Significant nutritional deficiency 

• Dependence on enteral feeding or oral nutritional supplement 

• Marked interference with psychosocial functioning 

Treatment:Psychotherapy (non pharmacological interventions for bulimia and anorexia) 

• Enhanced cognitive behavioural therapy (CBT-E)

• Family therapy 

• Interpersonal psychotherapy 

• Dialectical behavioral therapy

Dialectical behaviour therapy (Non-Pharmacological interventions Treatment:Psychotherapy- bulimia and anorexia)

Combines numerous cognitive-behavioural approaches to emotion regulation and distress tolerance 

Requires monitoring and commitment by the patient 

Individual therapy 

Building skills through skills group 

• Mindfullness 

• Interpersonal effectiveness 

• Emotion regulation 

• Distress tolerance skills 

Enhanced cognitive behaviour therapy (CBT-E) (Non-Pharmacological interventions Treatment:Psychotherapy-bulimia and anorexia)

• An empirically supported staged treatment designed specifically to help individuals with eating disorder achieve their personal recovery goals 

• Staged treatment

Stage 1 (Staged treatment (enhanced cognitive behaviour therapy: non pharm interventions psychotherapy)

Focused on understanding eating problem

Stage 2 Staged treatment (enhanced cognitive behaviour therapy: non pharm interventions psychotherapy)

Understanding processes that are maintaining the eating problem

Stage 3 Staged treatment (enhanced cognitive behaviour therapy: non pharm interventions psychotherapy)

Addressing concerns about shape and eating, enhancing ability to deal with day to day events and moods, addressing extreme  dietary restraint

Stage 4 Staged treatment (enhanced cognitive behaviour therapy: non pharm interventions psychotherapy)

Dealing with setbacks and maintaining gains

Benefits of Enhanced cognitive behaviour therapy (CBT-E) (Non-Pharmacological interventions Treatment:Psychotherapy-bulimia and anorexia)

• Well researched 

• User friendly

Drawbacks of Enhanced cognitive behaviour therapy (CBT-E) (Non-Pharmacological interventions Treatment:Psychotherapy-bulimia and anorexia)

Intervention may not always be available in all jurisdiction

Nursing assessment eating disorders

Screening 

• SCOFF eating disorders screening tool 

• CAGE screen for alcohol disorders 

Assessment 

• Head to toe

• Vital signs 

• Weight 

• BMI 

• Laboratory test 

Mental status examination 

Suicide risk assessment 

Nursing Interventions (Eating disorders) 

• Monitoring nutritional intake 

• Monitoring physical health status 

• Supportive counselling 

• Crisis prevention & intervention 

• Skill teaching coping with distress

• Skill teaching mindfulness 

• Skill teaching emotion regulation 

• Skill teaching interpersonal effectiveness 

• Individual advocacy 

• Systems level advocacy 

• Public education 

Refeeding syndrome

• Occurs when someone malnourished begins feeding again 

• Body adapts, metabolism changes (slowdown) 

• Body starts to us fat and protein 

• Refeeding= increased insulin, carb metabolism 

• Shifts in electrolytes (P,K,Mg) 

Refeeding syndrome (eating disorder nursing interventions) 

• Baseline bloodwork 

• Tailored diet plans 

• Referrals to dietitian

• Low and slow 

 Personality disorders 

Approx 7.8% of the population is diagnosed have a personality disorder 

Individuals with personality disorders represent 20% of emergency department and 25% of inpatient mental health hospital admissions 

Individuals living with personality disorders often  experience stigmatizing responses from health care providers when they seek health care services including:

• Poor communication 

• Inappropriate treatment

• Not having concerns taken seriously

Personality

• Complex pattern of characteristics, largely outside of the person's awareness 

• Distinctive patterns of perceiving, feeling, thinking, coping, and behaving 

• emerges within biopsychosocial framework

Personality disorder

• An enduring pattern of deviant inner experiences and behaviour 

• Differs from cultural expectations 

• Pervasive, inflexible, and stable 

• Leads to distress or impairment

Personality disorders diagnostic criteria 

• No sharp division exists between normal and “abnormal” personality functioning 

• Ten personality disorders are recognized as psychiatric diagnoses and are organized into three clusters 

• To receive a DSM-5 diagnosis of PD, an individual must demonstrate the criteria behaviours persistently and to such an extent that they impair the ability to function socially and occupationally 

Custer A: Social Aversion (types of personality disorders)

• Paranoid personality disorder 

• Schizoid personality disorder 

• Schizotypal personality disorder

Cluster B: Dysregulation in emotions and behaviour (types of personality disorders)

• Borderline personality disorder 

• Antisocial personality disorder

• Narcissistic personality disorder

• Histrionic personality disorder

Cluster C: Fearfulness (types of personality disorders)

• Avoidant personality disorder 

• Dependent personality disorder

• Obsessive compulsive personality disorder

Paranoid Personality Disorder (Cluster A disorder:social aversion)

• Mistrustful, avoid relationships that cannot control 

• Persistent ideas of self-importance

• Will be hypervigilant to any environmental changes

• Difficulty with developing and maintaining relationships

Schizoid Personality Disorder (Cluster A disorder:social aversion)

• Expressively impassive and interpersonally unengaged 

• Introverted and reclusive, engage in solitary activities

• Communication sometimes confused and lacks focus 

• Incapable of forming social relationships

• Minimum introspection, self-awareness, and interpersonal experiences

Schizotypal Personality Disorder (Cluster A disorder:social aversion)

• Eccentric 

• Pattern of social and interpersonal deficit 

• Void of close friends 

• Odd beliefs 

• Ideas of reference

• When psychosis present, symptoms mimic schizophrenia

Cluster B: Borderline personality disorder

• Pervasive patterns of instability of interpersonal relationships, self-image, and affects, as well as marked impulsivity that begins by early adulthood and is present in a variety of contexts. 

Manifestations of Borderline personality disorder (Cluster B)

• Regulating moods 

• Affective instability-shifts in moods

Identity disturbances (Manifestations of Borderline personality disorder (Cluster B)

• Role absorption- narrow definition of self 

• Painful incoherence-internal disharmony 

• Inconsistency in thoughts, feelings, and actions

Unstable interpersonal relationships (Manifestations of Borderline personality disorder (Cluster B)

• Fear of abandonment 

• Unstable, insecure attachments 

• overidealize/intense relationships 

Cognitive dysfunction (Manifestations of Borderline personality disorder (Cluster B)

• Maladaptive schemas

• Dichotomous thinking 

• Dissociation

Dysfunctional behaviours (Manifestations of Borderline personality disorder (Cluster B

• Impaired problem solving 

• Impulsivity 

• Self-injurious behaviours (parasuicidal behaviour)

Risk for suicide(Manifestations of Borderline personality disorder (Cluster B) 

Risk factors such as abuse and neglect

Antisocial personality disorder (Cluster B disorders)

• Behaviourally impulsive 

• Interpersonally irresponsible

• Fail to adapt to the ethical and social standards of community interpersonally engaging, but in reality lack empathy 

• Easily irritated, often aggressive

Histrionic personality disorder (Cluster B disorders)

• Attention seeking, life of the party, uncomfortable with single relationship 

• Lively and dramatic and draw attention to themselves by their enthusiasm, dress, and apparent openness 

• Become depressed when not center of attention

• Culturally influenced 

• May co-occur with other PDs, as well as anxiety disorders, substance abuse, and mood disorders

Narcissistic personality disorder (Cluster B disorders)

• Grandiose degree of self-love and self-importance

• Lacks empathy for others 

• Inexhaustible need for attention 

• Fantasies about power, unlimited success 

• Experiences personal insecurities

Cluster B personality disorders Manifestations

• Identity disturbances

• Unstable interpersonal relationships

• Cognitive dysfunction

• Dysfunctional behaviours

• Impulsivity 

• Self-injurious behaviours (parasuicidal behaviour) 

• Lack of commitment

• risk for suicide 

Avoidant personality disorder (Cluster C disorder)

• Avoiding interpersonal contacts and social situation 

• Perceiving themselves as socially inept 

Dependent (Cluster C disorder)

• Submissive pattern 

• Cling to others to be taken care of 

• Prevalent in clinical samples 

Obsessive-compulsive (Cluster C disorders)

• Different than OCD

• Not as many obsessions and compulsions 

• Functioning is not impacted

Interdisciplinary interventions (cluster personality disorders)

• Requires the entire health care team 

• In individuals with BPDF, there is evidence of the short term effects of mood stabilizers (e.g. topiramate) for emotional dysregulation and impulsive-agreession and second-generation antipsychotics (ee.g olanzapine) for cognitive-perceptual and impulsive-agreession) 

• Psychotherapy 

Personality disorders: Pharmacological interventions

• Antidepressants 

• Anxiolytics 

• Antipsychotics 

• Mood stabilizer 

Personality disorders: non-pharmacological interventions

• Psychodynamic psychotherapy 

• Dialectical behavior therapy 

• Cognitive therapy 

• Behaviour therapy 

• Interpersonal psychotherapy 

Personality disorders: nursing assessment 

Screening 

• McLean screening instrument for BPD (MSU_BPD)

Assessment

• Structured clinical interview for DSM V axis II personality disorders-patient questionnaire 

Mental status examination 

Suicide risk assessment 

Personality disorders: Nursing interventions 

• Crisis prevention & intervention 

• Supportive counseling 

• Monitoring and management 

• Skill teaching distress tolerance

• Skill teaching mindfulness 

• Skill teaching motion regulation 

• Skill teaching interpersonal effectiveness

• Individual advocacy 

• Systems level advocacy 

• Public education 

Biologic (Bio/psycho/social/spiritual interventions for individuals with BPD)

• Manage medications

• Prevent harm to self and others 

• Establish regular sleep routines 

• Encourage adequate nutrition 

• Observe for eating disorders

Social (Bio/psycho/social/spiritual interventions for individuals with BPD)

• Milieu management 

• Help establish new relationships for support 

• Group skills 

• Assertiveness classes 

Psychological (Bio/psycho/social/spiritual interventions for individuals with BPD)

• Recognizes abandonment and intimacy fears 

• Identify triggers for self-injury 

• Track emotion regulation 

• Teach and reinforce desired behaviours and communication skills 

Spiritual (Bio/psycho/social/spiritual interventions for individuals with BPD)

• Teach mindfulness or other distress-reducing skills 

• Maintain compassionate attitude 

• Support hope 

• Support spiritual activities

Autism: the DSM version 

• Persistent deficits in social communication and social interaction across multiple contexts 

• Restricted, repetitive patterns of behavior, interests, or activities

Autism social manifestations 

• social - emotional reciprocity- abnormal social approach , failure at back and fourth convo 

• Nonverbal communicative behaviours used to social interaction, ranging 

• developing , maintaining, and understanding relationships- difficulty adjusting to behavior to suit various social contexts 

Autism Behavioural manifestations 

• Stereotyped or repetitive motor movements, use of objects or speech 

• Insistence on sameness, inflexible, adherence to routines, or ritualized patterns of verbal or non verbal behaviours- distress with small changes in schedule 

• Highly restricted, fixated interests that are abnormal in intensity or focus- strong attachment to or with unusual objects

• Hyper- or hypoactivity to sensory input or usual interest in sensory aspects of the environment - indifference to pain/temperature, averse reaction to excessive stimulation of 5 senses 

ADHD: The DSM version 

• Symptoms and/or behaviours that have persisted >6months in > 2 settings (e.g school, home, church) 

• Symptoms have negatively impacted academic, social, and/or occupational functioning 

• In patients aged <= 17 years, >=6 symptoms are necessary; in those aged .>=17 years, >= 5 symptoms are necessary 

• evidence that several symptoms were present before the age of 12 years 

• Can be classified as mild, moderate, or severe based on symptom severity 

• Not better accounted for by a different psychiatric disorder 

• Do not occur exclusively during a psychotic disorder 

• Not exclusively a manifestation of oppositional behaviour 

ADHD diagnostic criteria 

• Inattentive type

• hyperactive/impulsive type

• Combined type

• Predominantly inattentive type

• Predominantly hyperactive/impulsive type

Inattentive type (adhd diagnostic criteria)

Displays poor listening skills • Loses and/or misplaces items needed to complete activities or tasks Sidetracked by external or unimportant stimuli • Forgets daily activities • Diminished attention span • Lacks ability to complete schoolwork and other assignments or to follow instructions • Avoids or is disinclined to begin homework or activities requiring concentration • Fails to focus on details and/or makes thoughtless mistakes in schoolwork or assignment

Hyperactive symptoms (hyperactive/impulsive type (adhd diagnostic criteria)

• Squirms when seated or fidgets with feet/hands • Marked restlessness that is difficult to control • Appears to be driven by “a motor” or is often “on the go”• Lacks ability to play and engage in leisure activities in a quiet manner • Incapable of staying seated in class • Overly talkative

Impulsive symptoms (hyperactive/impulsive type (adhd diagnostic criteria)

• Difficulty waiting turn • interrupts or intrudes into conversations and activities of others • impulsively blurts out answers before questions completed

Combined type (adhd diagnostic criteria)

Patient meets both inattentive and hyperactive/impulsive criteria for thee past 6 months

Predominantly inattentive type (adhd diagnostic criteria)

Patient meets inattentive criterion, but not hyperactive/impulse criterion, for the past 6 months

Predominantly hyperactive/impulsive type (adhd diagnostic criteria)

• Patient meets hyperactive/impulse criterion, but not inattentive criterion, for the past 6 months 

Causes of Under- and Mis-Identification- Autism

• Gender bias in diagnostic criteria and gendered stereotypes

• Overlapping diagnoses/diagnostic criteria

• Racism, bias, and stereotypes

• Access to diagnosis and services

Gender bias in diagnostic criteria and gendered stereotypes (Under- and Mis-Identification- Autism)

• The stereotype of the white middle-class autistic boy continues despite aims to broaden diagnostic criteria 

• Girls were/are less likely to be recognized as autistic