integ: abpsych (feeding, eating, and elimination disorders)

Feeding and Eating Disorders

characterized by a persistent disturbance of eating or eating-related behavior that results in the altered consumption or absorption of food that significantly impair physical health, psychological well-being, or social functioning

BINGE EATING:

Large amounts of food in a discrete period with a "loss of control."

COMPENSATORY BEHAVIORS

Vomiting, laxatives, fasting, or excessive exercise to prevent weight gain.

THE REWARD SYSTEM

Shared neural systems involve regulatory self-control and reward pathways.

substance use disorders

Some symptoms resemble what (cravings, compulsive use)

Pica Disorder

• eating of one or more non-nutritive, nonfood substances on a persistent basis over a period of at least 1 month

• May also manifest in pregnancy as  cravings

• Typical substances ingested tend to vary with age and availability and might include paper, soap, cloth, hair, string, wool, soil, chalk, talcum powder, paint, gum, metal, pebbles, charcoal or coal, ash, clay, starch, or ice.

• does not apply to ingestion of diet products that have minimal nutritional content.

Pica disorder

A. Persistent eating of nonnutritive, nonfood substances over a period of at least 1 month.

B. The eating of nonnutritive, nonfood substances is inappropriate to the developmental level of the individual.

C. The eating behavior is not part of a culturally supported or socially normative practice.

D. If the eating behavior occurs in the context of another mental disorder (e.g., intellectual disability [intellectual developmental disorder], autism spectrum disorder, schizophrenia) or medical condition (including pregnancy), it is sufficiently severe to warrant additional clinical attention.

PICA

COURSE: Most common in childhood, but can occur in adults (often alongside intellectual disabilities).

RISKS: Must be inappropriate for the individual’s developmental level and not a culturally sanctioned practice.

Rumination Disorder

• repeated regurgitation of food occurring after feeding or eating over a period of at least 1 month

• Food may be re-chewed, re-swallowed, or spit out.

• Previously swallowed food that may be partially digested is brought up into the mouth without apparent nausea, involuntary retching, or disgust

• Not due to medical conditions (like GERD) or other eating disorders.

Rumination Disorder

A. Repeated regurgitation of food over a period of at least 1 month. Regurgitated food may be re-chewed, re-swallowed, or spit out.

B. The repeated regurgitation is not attributable to an associated gastrointestinal or other medical condition (e.g., gastroesophageal reflux, pyloric stenosis).

C. The eating disturbance does not occur exclusively during the course of anorexia nervosa, bulimia nervosa, binge-eating disorder, or avoidant/restrictive food intal<e disorder.

D. If the symptoms occur in the context of another mental disorder (e.g., intellectual disability [Intellectual developmental disorder] or another neurodevelopmental disorder), they are sufficiently severe to warrant additional clinical attention.

In remission

After full criteria for the disorder were previously met, the criteria have not been met for a sustained period of time.

RUMINATION DISORDER

Often occurs in infants (3–12 months) and may remit spontaneously.

In individuals with neurodevelopmental disorders, it may serve a self-soothing or self-stimulating function.

Avoidant/Restrictive Food Intake Disorder

• avoidance or restriction of food intake causing significant weight loss /  nutritional deficiency

• may be based on the sensory characteristics of qualities of food

• May also represent a conditioned negative response associated with food intake following, or in anticipation of, an aversive experience

Avoidant/Restrictive Food Intake Disorder

A. An eating or feeding disturbance (e.g., apparent lack of interest in eating or food; avoidance based on tlie sensory ciiaracteristics 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:

1. Significant weight loss (or failure to achieve expected weight gain or faltering growth in children).

2. Significant nutritional deficiency.

3. Dependence on enteral feeding or oral nutritional supplements.

4. Marked interference with psychosocial functioning.

B. The disturbance is not better explained by lack of available food or by an associated culturally sanctioned practice.

C. The eating disturbance 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.

D. The eating disturbance 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.

"Dependence" on enteral feeding or oral nutritional supplements

• supplementary feeding is required to sustain adequate intake.

• infants with failure to thrive who require nasogastric tube feeding, children with neurodevelopmental disorders who are dependent on nutritionally complete supplements, and individuals who rely on gastrostomy tube feeding

Avoidant/Restrictive Food Intake Disorder

• a person limits the amount or types of food they eat

• The issue is with food itself (taste, texture, fear, or lack of interest)

Avoidant/Restrictive Food Intake Disorder

• A child only eats white foods (rice, bread) due to texture sensitivity

• Someone avoids eating after a choking incident due to fear

• A person consistently forgets to eat or has very low interest in food

Anorexia Nervosa

• person eats only minimal amounts of food or exercises vigorously to offset food intake so body weight sometimes drops dangerously

• Decreased body weight is the most notable feature

• never satisfied with their weight loss

• They are so successful at losing weight that they put their lives in considerable danger

anorexia nervosa

ONSET: Typically adolescence/young adulthood; often triggered by a stressful life event.

PROGNOSIS: Variable course (full recovery, fluctuating, or chronic).Most achieve remission within 5 years.

CAUSES OF DEATH: Medical complications or suicide.

RESTRICTION:

Leading to significantly low body weight.

FEAR:

Intense fear of gaining weight or "becoming fat."

DISTURBANCE:

Distorted view of body weight/shape or lack of recognition of the severity of low weight.

RESTRICTING TYPE:

Weight loss via dieting, fasting, and exercise.

BINGE-EATING/PURGING TYPE

Recurrent episodes of bingeing or purging (vomiting, laxatives).

Mild Anorexia

BMI > 17 kg/m^2

Moderate Anorexia

BMI 16 - 16.99 kg/m^2

Severe Anorexia

BMI 15 - 15.99 kg/m^2

Extreme Anorexia

BMI < 15 kg/m^2

Common Treatments in Anorexia Nervosa

• Most important goal is to restore the patient’s weight to a point that is at least within the low normal range

• Cognitive-Behavioral Therapy (CBT)

• Cognitive-Behavioral Therapy-Enhanced (CBTE)

• Family-based Treatment (FBT)

Anorexia Nervosa

A. Restriction of energy intal<e relative to requirements, leading to a significantly low body weigfit in tfie context of age, sex, developmental trajectory, and physical health. Significantly low weight is defined as a weight that is less than minimally normal or, for children and adolescents, less than that minimally expected.

B. Intense fear of gaining weight or of becoming fat, or persistent behavior that interferes with weight gain, even though at a significantly low weight.

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

Anorexia nervosa, restricting type

During the last 3 months, the individual has not engaged in recurrent episodes of binge eating or purging behavior (i.e., self-induced vomiting or the misuse of laxatives, diuretics, or enemas). This subtype describes presentations in which weight loss is accomplished primarily through dieting, fasting, and/or excessive exercise.

anorexia nervosa, Binge-eating/purging type:

During the last 3 months, the individual has engaged in recurrent episodes of binge eating or purging behavior (i.e., self-induced vomiting or the misuse of laxatives, diuretics, or enemas).

Anorexia Nervosa, In partial remission

After full criteria for anorexia nervosa were previously met. Criterion A (low body weight) has not been met for a sustained period, but either Criterion B (intense fear of gaining weight or becoming fat or behavior that interferes with weight gain) or Criterion C (disturbances in self-perception of weight and shape) is still met.

Bulimia Nervosa

• binges are followed by self-induced vomiting, excessive use of laxatives, or other attempts to purge

• Vomiting is the most common inappropriate compensatory behavior

• Amount of food eaten and eating is experienced as out of control

bulimia nervosa

A. Recurrent episodes of binge eating. An episode of binge eating is characterized by

both of the following:

1. Eating, in a discrete period of time (e.g., within any 2-hour period), an amount of food that is definitely larger than what most individuals would eat in a similar period of time under similar circumstances.

2. A sense of lack of control over eating during the episode (e.g., a feeling that one cannot stop eating or control what or how much one is eating).

B. Recurrent inappropriate compensatory behaviors in order to prevent weight gain, such as self-induced vomiting; misuse of laxatives, diuretics, or other medications; fasting; or excessive exercise.

C. The binge eating and inappropriate compensatory behaviors both occur, on average, at least once a week for 3 months.

D. Self-evaluation is unduly influenced by body shape and weight.

E. The disturbance does not occur exclusively during episodes of anorexia nervosa.

bulimia nervosa In partial remission

After full criteria for bulimia nervosa were previously met, some, but not all, of the criteria have been met for a sustained period of time.

mild bulimia nervosa

An average of 1-3 episodes of inappropriate compensatory behaviors per week.

Moderate Bulimia Nervosa

An average of 4-7 episodes of inappropriate compensatory behaviors per week.

Severe Bulimia Nervosa

An average of 8-13 episodes of inappropriate compensatory behaviors per week.

Extreme

An average of 14 or more episodes of inappropriate compensatory behaviors per week.

negative affect

The most common antecedent of binge eating is

thyroid hormone

Individuals with bulimia nervosa may take what in an attempt to avoid weight gain.

anabolic–androgenic steroids

Men tend to abuse what to increase muscle mass and “bulk up”

Psychological Core: All three involve a heavy emphasis on body weight and shape in self-evaluation (though this is not a requirement for BED).

Neurological Link: Potential involvement of the brain‘s reward and self-control systems, similar to substance use disorders.

Health Impact: All lead to significant impairment inpsychosocial functioning and physical health.

BINGE-EATING DISORDER (BED)

ASSOCIATED SYMPTOMS (MUST HAVE 3+):

Eating rapidly.

Eating until uncomfortably full.

Eating large amounts when not hungry.

Eating alone due to embarrassment.

Feeling disgusted, depressed, or guilty afterward.

Anorexia Nervosa (AN)

Body Weight: Significantly low weight

binge eating: Only in Binge/Purge type.

Compensatory Behavior: Common (purging/exercise)

loss of control: Felt during binges (if any)

Primary Fear: Intense fear of weight gain.

Bulimia Nervosa (BN)

Body Weight: Usually normal weight or overweight.

Binge Eating: Required (once/week).

Compensatory Behavior: Required (purging/fasting).

Loss of Control: Felt during binges.

Primary Fear: Undue influence of weight.

Binge-Eating Disorder (BED)

Body Weight: Often associated with obesity.

Binge Eating: Required (once/week).

Compensatory Behavior: None (absent).

Loss of Control: Felt during binges.

Primary Fear: Marked distress about binges.

Reverse Anorexia Nervosa

disorder in men where they are extremely concerned about looking small, even though they were muscular

leptin

• Reduced levels of what might be associated with excessive efforts to keep weight down

• A Hormone acting in the hypothalamus to produce feelings of fullness

• Keep people from overeating

postovulatory

Emotional eating behavior and binge eating frequencies peaked in the what phases of the menstrual cycle

Elimination Disorders

• inappropriate elimination of urine or feces and are usually first diagnosed in childhood or adolescence

• Based on developmental age and not solely on chronological age

• Both disorders may be voluntary or involuntary

• May co-occur

Enuresis Disorder

repeated voiding of urine into inappropriate places

Repeated urination in bed or clothes

Monosymptomatic Enuresis

• Most common subtype of enuresis

• Involves incontinence only during nighttime sleep

• Typically occurs during the first one-third of the night

• The only problem is bedwetting

• No daytime urinary issues or other bladder dysfunction

Urinary Incontinence

loss of control over urination

Also called diurnal-only subtype

Stress incontinence

• Leakage with increased abdominal pressure

• Triggers: coughing, sneezing, laughing

• Example: Urine leaks when someone laughs hard

Urge incontinence

• Sudden, intense urge to urinate followed by leakage

• Often linked to overactive bladder

• Example: Can’t reach the bathroom in time

Overflow incontinence

• Bladder doesn’t empty fully → constant dribbling

• Example: Frequent small leaks due to a full bladder

Functional incontinence

• Physical or cognitive issues prevent reaching the toilet

• Example: A person with dementia or mobility problems

Nonmonosymptomatic enuresis

bedwetting occurs together with other daytime urinary symptoms.

ex: An 8-year-old:

• Wets the bed at night

• Also has daytime accidents and frequently rushes to the bathroom

enuresis

A. Repeated voiding of urine into bed or clothes, whether involuntary or intentional.

B. The behavior is clinically significant as manifested by either a frequency of at least twice a week for at least 3 consecutive months or the presence of clinically significant distress or impairment in social, academic (occupational), or other important areas of functioning.

C. Chronological age is at least 5 years (or equivalent developmental level).

D. The behavior is not attributable to the physiological effects of a substance (e.g., a di-uretic, an antipsychotic medication) or another medical condition (e.g., diabetes, spinabifida, a seizure disorder).

Nocturnal only

Passage of urine only during nighttime sleep.

Diurnal only

Passage of urine during waking hours.

Nocturnal and diurnal

passage of urine during nighttime sleep and waking hours

primary type enuresis

• the individual has never established urinary continence

• The child has always had episodes of bedwetting

• There has not been a sustained dry period

• begins at age 5 years

secondary type enuresis

• disturbance develops after a period of established urinary continence.

• The child was dry for at least 6 months

• Then bedwetting or urinary accidents recur

• between ages 5 and 8 years

Bell-and-Pad Procedure

• Child sleeps on a pad that is wired to a battery-operated bell

• The bell is set off at the first few drops of urine

• Through classical conditioning, the child comes to associate bladder tension with awakening

Encopresis Disorder

• repeated passage of feces into inappropriate places

• Leakage can be infrequent to continuous, occurring mostly during the day and rarely during sleep

• inappropriate defecation after toilet-training age

Encopresis disorder

A. Repeated passage of feces into inappropriate places (e.g., clothing, floor), whether involuntary or intentional.

B. At least one such event occurs each month for at least 3 months.

C. Chronological age is at least 4 years (or equivalent developmental level).

D. The behavior is not attributable to the physiological effects of a substance (e.g., laxatives) or another medical condition except through a mechanism involving constipation.

encopresis With constipation and overflow incontinence:

There is evidence of constipation on physical examination or by history.

encopresis Without constipation and overflow incontinence:

There is no evidence of constipation on physical examination or by history.

encopresis primary type

a child has never achieved consistent bowel control.

The child has always had difficulty controlling bowel movements

begins at age 5 years

encopresis second type

• a child previously had bowel control but begins having inappropriate defecation again

• The child was toilet trained for at least 6 months

• Then inappropriate fecal elimination reoccurs

• between ages 5 and 8 years

binge-eating disorder

A. Recurrent episodes of binge eating. An episode of binge eating is characterized

by both of the following:

1. Eating, in a discrete period of time (e.g., within any 2-hour period), an amount of food that is definitely larger than what most people would eat in a similar period of time under similar circumstances.

2. A sense of lack of control over eating during the episode (e.g., a feeling that one cannot stop eating or control what or how much one is eating).

B. The binge-eating episodes are associated with three (or more) of the following:

1. Eating much more rapidly than normal.

2. Eating until feeling uncomfortably full.

3. Eating large amounts of food when not feeling physically hungry.

4. Eating alone because of feeling embarrassed by how much one is eating.

5. Feeling disgusted with oneself, depressed, or very guilty afterward.

C. Marked distress regarding binge eating is present.

D. The binge eating occurs, on average, at least once a week for 3 months.

E. The binge eating is not associated with the recurrent use of inappropriate compensatory behavior as in bulimia nervosa and does not occur exclusively during the course of bulimia nervosa or anorexia nervosa.

binge-eating

Most obese individuals do not engage in recurrent