Medicine Exam 5: Pediatric Eating Disorders

Lecture 6

1. Identify and recognize the etiology of eating disorders, including the genetic component

• Genetic predisposition: AN and BN are as inheritable as other serious psychiatric illnesses. - No single gene explanation, but genetics contribute to heightened risk. - Increased risk with family history: Anorexia (12×), Bulimia (4×). - Personality traits with genetic links: anxious, fearful, perfectionistic, rejection sensitive. - Neurochemical imbalances affecting well-being, hunger, appetite, digestion. - ED behaviors (dieting, bingeing, purging, excessive exercise) alter neurochemistry. - Malnutrition can shrink the brain and contribute to rigid thinking. - ED symptoms may perpetuate biological and psychological features.

1960s vs. now

• The number of people diagnosed with an eating disorder has doubled since the.

2. Identify and recognize the incidence of eating disorders

- Up to 24 million people in the US and 70 million worldwide struggle with anorexia, bulimia, or binge eating disorder. - Diagnoses have doubled since the 1960s. - At least 50,000 individuals will die as a direct result of their eating disorder. - Anorexia Nervosa has the highest mortality rate of any psychiatric disorder (up to 15%).

3. Identify and recognize predisposing factors and clinical profiles for patients with anorexia nervosa and bulimia nervosa

- Anorexia Nervosa: - Wants to lose weight regardless of size/shape. - Always on a diet, terrified of gaining weight. - Poor body image, hair loss, cold intolerance. - Talks excessively about calories/food. - Anxiety, mood swings, isolation. - Bulimia Nervosa: - Consumes large quantities of food in one sitting. - Dieting, frequent bathroom use after meals. - Dental issues, swollen glands, irritated knuckles. - Weight fluctuations, secrecy, depression. - Shared Predisposing Factors: - Low self-esteem, perfectionism, trauma history. - Mood and anxiety disorders, impulsivity, emotional dysregulation. - Sociocultural pressures, body image disturbance. - Peer influences, chronic illness, food insecurity.

4. Identify, recognize, and differentiate the 2 types of anorexia

- Restricting Type: Primarily weight loss through dieting, fasting, or excessive exercise. - Binge-Eating/Purging Type: Regular episodes of binge eating or purging (e.g., vomiting, misuse of laxatives). (Note: DSM-5 criteria referenced but not detailed in slides.)

5a. Anorexia Nervosa

- Signs/Symptoms: - Wants to lose weight regardless of size/shape. - Always dieting, terrified of gaining weight. - Poor body image, hair loss, cold intolerance. - Talks excessively about food/calories. - Anxiety, mood swings, isolation. - Complications: - Highest mortality rate of any psychiatric disorder (up to 15%). - Malnutrition, cognitive impairment, medical complications. - Treatment Options: - CBT, DBT, Exposure & Response Prevention, Family-Based Treatment (for youth), Transdiagnostic CBT. - Emotion awareness training, food exposures, body image exposures.

5b. Bulimia Nervosa

- Signs/Symptoms: - Large food consumption in one sitting. - Frequent dieting, bathroom use after meals. - Dental issues, swollen glands, bloodshot eyes. - Weight fluctuations, secrecy, depression. - Complications: - Tooth decay, GI issues, electrolyte imbalance. - Treatment Options: - CBT, DBT (especially with self-harm), Motivational Interviewing, Transdiagnostic CBT.

5c. Binge Eating Disorder (BED)

- Signs/Symptoms: - Eating alone or secretly. - Eating until uncomfortably full or sick. - Shame, guilt, disgust after eating. - Eating rapidly, without hunger. - Complications: - Type 2 diabetes, hypertension, high cholesterol. - Gallbladder disease, osteoarthritis, sleep apnea. - GI problems, PCOS, depression, anxiety, panic attacks. - Treatment Options: - CBT, Interpersonal Therapy, Motivational Interviewing, Transdiagnostic CBT.

5d. Avoidant/Restrictive Food Intake Disorder (ARFID)

- Signs/Symptoms: - Picky/selective eating, sensory sensitivity. - Anxiety, GI symptoms, fears of choking/vomiting. - Food allergies, safe/unsafe food categorization. - Describes food using non-food terms (e.g., insects, dirt). - Subtypes: - Sensory, Behavioral/Anxiety-Based, Fear-Based, Temperament-Based, Medical Symptom-Related. - Treatment Options: - Exposure therapy (food, interoceptive, body image), CBT, emotion awareness training.

6. Given a clinical scenario, appropriately diagnose and recommend treatments and/or managements of the disorders listed in the above objectives

- Scenario Summary: - 14-year-old with significant weight loss and food restriction. - Strong avoidance of foods, lack of interest in eating. - No concern about body image/weight/shape. - Safe/unsafe food categorization. - Picky eating, sensory aversion (textures). - Likely Diagnosis: Avoidant/Restrictive Food Intake Disorder (ARFID). - Supporting Features: - Sensory-based food avoidance (slimy, soggy, crunchy textures). - Lack of body image disturbance. - Presence of safe/unsafe food rules. - Recommended Treatments: - Exposure therapy (food exposures, interoceptive exposures). - Emotion awareness training. - CBT tailored to ARFID subtype. - Multidisciplinary team: therapist, nutritionist, psychiatrist, nursing support. - Level of Care Considerations: - Assess medical status, weight (%IBW), motivation, co-occurring disorders. - If medically stable and motivated: OP or IOP. - If poor motivation, acute weight decline, or food refusal: RES or IP.

Ability to Control Compulsive Exercise: Step Up

- OP: Client can manage urges on their own. - PHP/RES/IP: Some degree of external structure beyond self-control required to prevent client from compulsive exercise* - *Rarely a sole indication for increasing LOC

Anorexia Nervosa Affects your whole body

Brain and Nerves can't think right, fear of gaining weight, sad, moody, irritable, bad memory, fainting, changes in brain chemistry Hair hair thins and gets brittle Heart low blood pressure, slow heart rate, fluttering of the heart, heart failure Blood anemia and other blood problems Muscles and Joints weak muscles, swollen joints, fractures, osteoporosis Kidneys kidney stones, kidney failure Fluids low potassium, magnesium, and sodium Intestines constipation, bloating Hormones periods stop, growing problems, trouble getting pregnant. If pregnant, higher risk for miscarriage, having a C-section, baby with low birthweight, and post partum depression Skin bruise easily, dry skin, growth of fine hair all over body, get cold easily, yellow skin, nails get brittle

Anorexia Nervosa External S/S

· Weigh self frequently, watching videos about food hep feel better • Is thin and continues to get thinner • Diets even though not underweight • Terrified of gaining weight • Has a distorted body image • Loss of hair or thinning of hair • Loss of menses • Is cold even when temperature is warm • Talks excessively about calories, food and cooking • Increased isolation

Anorexia Nervosa Malnutrition

· Malnutrition impacting whole body = across systems ex. Fractures, osteoporosis, anemia · Growth of fine hairs all over = body trying to get warm any way possible · This is what’s happening on the “inside” · Refeeding Syndrome-Refeeding syndrome appears when food is introduced too quickly after a period of malnourishment. Refeeding can be stressful on the body; cardiac workload increases and there are shifts in electrolytes. · Sometimes there aren’t enough minerals needed for breakdown of fats & proteins.

Anorexia Nervosa mortality

- has the highest mortality rate of any psychiatric disorder (up to 15%).

Anorexia Nervosa Signs/Symptoms

- Wants to lose weight regardless of size/shape - Seems to be always on a diet - Terrified of gaining weight - Has poor body image - Loss of hair or thinning of hair - Is cold even when temperature is warm - Talks excessively about calories, food, and cooking - Anxiety, mood swings, irritability - Increased isolation

ARFID

· Extreme picky eating · Major issue in pediatrics · Can occur throughout the day · Loss socialization when not eating with others · Have food just not eating · May never get off the kids menu, leaving it is very stressful

ARFID complication

May generalize food allergies, and be fearful of other foods

Bandura’s Social Cognitive Theory

People are MORE likely to compare themselves to PEERS for both social and physical attributes including weight, height, and body shape. We compare with those who are similar to us!

BED Factors

· Presence of binge eating appears to confer additional medical and psychological consequences above and beyond those accounted for by obesity alone. · Type II diabetes- 14% among BE at least 2X week · 4% in matched weight control/age · Significant relationship between glycemic control and BE among Type II independent of weight · Report a lower quality of life compared to those with obesity only · BED-Obese overall health status is significantly lower than US norms and Non-BED ·

BED trigger

· Emotional rather than physical hunger cues · No purging, excessive exercise/laxative use

BED: Polycystic Ovary Syndrome

· An estimated 50% to 70% of women with PCOS are also insulin resistant and experience weight gain in the abdominal area, difficulty losing weight, hypoglycemic episodes, and intense cravings for carbohydrates.2,3 In addition, many women with PCOS are overweight or obese and are at risk for developing diabetes and heart disease. Other signs and symptoms of PCOS may vary among individuals both in intensity and type and include excessive hair growth on the face and body (hirsutism), alopecia, acne, skin problems, and irregular or absent periods. Because most of these signs and symptoms have a direct effect on body image, not to mention struggles with weight and intense carbohydrate cravings, many researchers have questioned the theory that a relationship exists between PCOS and eating disorders. · The Emotional Toll · For example, at a time when a young woman’s self-esteem is vulnerable, she may start to experience acne, excessive hair growth on her face and other parts of her body, and weight gain in her midsection—setting her apart from her peers. Not knowing she has PCOS or why her body is reacting the way it is, she may begin to blame herself and hate her body. Struggling with these issues at such a vulnerable time can lead many young women to deal with emotional distress through unhealthy dieting practices such as taking laxatives and diet pills, fasting, and engaging in excessive exercise and vomiting—all of which could set the stage for a lifetime of eating issues and body hatred. ·

Binge Eating Disorder Signs & Symptoms

- Eating alone/eating secretly - Eating until uncomfortably full or sick - Feelings of shame, guilt, disgust after eating - Eating rapidly in a short period of time - Eating without hunger

Biological Factors

- Imbalance of chemicals in the brain that control sense of well being, hunger, appetite and digestion. - Dieting, bingeing, purging and excessive exercise alters neurochemistry. - Many of the physical and psychological features of EDs are actually perpetuated by the ED symptoms - If someone is starving, underweight, binge eating or purging, their ability to see a different perspective may be limited by the physical effects of their disordered eating. - Alterations in neurochemistry potentially results in physiological addiction (self medication—release of endorphins)

Biological: Dieting

can alter appetite regulation Metabolism Mood brain chemistry In vulnerable youngsters can set off a downward spiral of events, as they are coping with biological and development changes. Endorphins interact with receptors in the brain that reduce perception of pain.

Biological: malnutrition

causes brain to shrink and contributes to rigid thinking

Biological: Temperament

aspects of an individual’s personality that are regarded as innate rather than learned.

Body Image

- About emotions - About how we experience emotions in our body - About the experience of buried emotions - Memories we hold in our body - Beliefs we have about ourselves/others

Body Image Concepts

- What you believe about your appearance (including your memories, assumptions, and generalizations) - How you see yourself when you look in the mirror or when you picture yourself in your mind.

Body Image Disturbance

How I see my body How I think others see my body How I experience living in my body Susan Kleinman: “many of the women I see bury their feelings and the burial ground is the body itself” Where in the body are the emotions stored, locked, experienced and buried

Body Image Exposures

- Viewing Body = Stimulus of Emotion - Abstaining from ritualized checking or avoidance - Describing appearance in neutral language - *Learning to tolerate negative emotions

Broaching the Subject: Preparation

- Ask gentle questions, calmly express your concern, talk of your observations - Remember—Minimization and denial are often part of the ED voice - Do not ignore symptoms or give up on the person - Let them know that you know they have a problem. It may be a long while before they themselves can confront and admit that they have a problem - Choose the moment carefully—a relaxed atmosphere is best, away from mealtimes - Do not try to fight the ED with logic. EDs are irrational disorders. - Be prepared for setbacks, especially initially

Broaching the Subject: Scripting

- Describe the facts as you see them calmly and with warmth: “I see you think….I think you feel…..I noticed that….How can I help?” - Listen without judgment: “Everyone has different views. This is not the way I see things; I accept you feel differently.” - Listen carefully to the answers: “Sounds like this might be the way you see things….? Have I got that right?” - Use reflective listening and affirmation to build trust

Bulimia Nervosa cost

· Money on food = buy Bulk

Bulimia Nervosa Dentistry

· Dentist can find first =corrosion from acid

Bulimia Nervosa S/S

Body constipated, delayed emptying = body doesn’t know which hole food leave out of Purging results in dehydration, loss of K and Na Electrolyte imbalances Inflammation/ruptures of the esophagus Menstrual irregularities Experiences & obsesses on frequent fluctuations in weight, even though they are “normal weight”

Bulimia Nervosa Signs/Symptoms

- Consumption of large quantities of food in a sitting - Always on a diet - Uses the bathroom frequently after meals - Has problems with their teeth - Swollen glands, irritated knuckles, bloodshot eyes - Spends excessive money on food - Experiences & obsesses on frequent fluctuations in weight = fast not gradual - Depressed moods, secretive and withdrawn

Changing Face of Eating Disorders

EDs affect every race, age, gender, SES. Women are more commonly affected. 20 million women and 10 million men will have a diagnosable ED at some point in their lives.

Child with ARFID May Experience

- Picky/selective eating habits - Sensory sensitivity - Generalized anxiety - GI symptoms - Fears of choking/vomiting - Food allergies - (Fox, Coulthard, Williamson & Wallis, 2018) - Foods that are “safe” and “unsafe” - Some perceive certain types of food as inedible and describe food using non-food substances (e.g. insects, dirt, lawn clippings)

Co-morbidity in ED

- Substance Abuse - Anxiety Disorders - Mood Disorders

Co-occurring Disorders Criteria: Step Up

- OP/IOP/PHP: Consider other diagnoses (substance use, depression, anxiety), as these can influence LOC recommendation - RES/IP: Any other diagnosis that would require hospitalization

Complications of BED

- Type 2 diabetes - High Blood pressure - High cholesterol - Gallbladder disease - Osteoarthritis - Joint and muscle pain - Sleep apnea - Gastrointestinal problems (reflux) - Certain types of cancer - Polycystic Ovary Syndrome - Emotional problems, such as depression, anxiety and panic attacks

Dialectical behavior therapy (DBT)

DBT skills training was originally developed to treat chronically suicidal individuals diagnosed with borderline personality disorder, but is effective in treating a wide range of other disorders such as substance dependence, depression, PTSD, and EDs. DBT is made up of 4 modules: core mindfulness, distress tolerance, emotional regulation, and interpersonal effectiveness. The modules are designed to help people better manage behaviors, emotions, and thoughts.

Diverse Symptoms Function Similarly

- Unpleasant Internal Experience - Emotional Avoidance and Unwillingness - Avoidant, Symptomatic Behavior - Temporary Relief from Unpleasant Internal Experience - Long Term Consequences

Diversity in ED

- Age group - Ethnicity - SES - LGBTQ+ - Size

DSM-5 Criteria for Anorexia Nervosa

Diagnostic Criteria · A. Restriction of energy intake relative to requirements, leading to a significantly low body weight in the 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 the 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. Coding note: The ICD-9-CM code for anorexia nervosa is 307.1, which is assigned regardless of the subtype. The ICD-10-CM code depends on the subtype (see below). · Specify whether: Subtypes · (F50.01) Restricting type: During the last 3 months, the individual has not engaged in re-current episodes of binge eating or purging behavior (i.e., self-induced vomiting or the mis-use of laxatives, diuretics, or enemas). This subtype describes presentations in which weight loss is accomplished primarily through dieting, fasting, and/or excessive exercise. · (F50.02) 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).

DSM-5 Criteria for Avoidant/Restrictive Food Intake Disorder (ARFID)

A. An eating or feeding disturbance (e.g., apparent lack of interest in eating or food; avoid-ance based on the sensory characteristics of food; concern about aversive conse-quences 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 ner-vosa 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 bet-ter 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.

DSM-5 Criteria for 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.

DSM5 Criteria – Other Specified Feeding or Eating Disorder (OSFED)

#1 =body difference #5 = unique, not eating at night is distressing This category applies to presentations in which symptoms characteristic of a feeding and eating disorder that cause clinically significant distress or impairment in social, occupation-al, or other important areas of functioning predominate but do not meet the full criteria for any of the disorders in the feeding and eating disorders diagnostic class. The other spec- ified feeding or eating disorder category is used in situations in which the clinician chooses to communicate the specific reason that the presentation does not meet the criteria for any specific feeding and eating disorder. This is done by recording "other specified feeding or eating disorder" followed by the specific reason (e.g., "bulimia nervosa of low frequency"). Examples of presentations that can be specified using the "other specified" designation include the following: 1. Atypical anorexia nervosa: All of the criteria for anorexia nervosa are met, except that despite significant weight loss, the individual's weight is within or above the normal range. 2. Bulimia nervosa (of low frequency and/or limited duration): All of the criteria for bulimia nervosa are met, except that the binge eating and inappropriate compensatory behaviors occur, on average, less than once a week and/or for less than 3 months. 3. Binge-eating disorder (of low frequency and/or limited duration): All of the criteria for binge-eating disorder are met, except that the binge eating occurs, on average, less than once a week and/or for less than 3 months. 4. Purging disorder: Recurrent purging behavior to influence weight or shape (e.g., self-induced vomiting; misuse of laxatives, diuretics, or other medications) in the absence of binge eating. 5. Night eating syndrome: Recurrent episodes of night eating, as manifested by eating after awakening from sleep or by excessive food consumption after the evening meal. There is awareness and recall of the eating. The night eating is not better explained by external influences such as changes in the individual's sleep-wake cycle or by local so-cial norms. The night eating causes significant distress and/or impairment in function- ing. The disordered pattern of eating is not better explained by binge-eating disorder or another mental disorder, including substance use, and is not attributable to another medical disorder or to an effect of medication.

Eating Disorders as Emotional Disorders

- Behavioral attempts to influence, change, or control painful emotional states - Function to regulate affect/provide momentary relief from aversive emotions - Therefore, recovery requires experiential challenge (doing things that have been habitually avoided) and reducing avoidance strategies

EBTs for Eating Disorders

- Family-Based Treatment - Children & adolescents only - Motivational Interviewing - Adaptation using text messaging to address binge-purge behaviors - Interpersonal - Most effect for binge-eating - DBT - Bulimia & self-harm - Exposure & Response Prevention - Anorexia with restrictive food intake - CBT - All EDs, and many other co-morbid conditions - Transdiagnostic CBT (The Unified Protocol, UP) - All EDs, and emotional disorders

ED research

· In a study recording 2 weeks of data from BN participants who were given hand held computers: · More negative affect, higher anger/hostility and stress reported on days when binge eating and vomiting occurred · Binge purge behaviors are strongly negatively reinforced by allowing escape or avoidance of strongly negative affective states. · Purging and laxative abuse has been shown to reduce negative affect prompted by binge eating. · Among patients with EDs, anxiety is one dimension of negative affect which serves as a precursor to binge eating, vomiting and dietary restriction. One potential explanation for this relationship is that anxiety is viewed to have unacceptable negative consequences and therefore is temporarily avoided or suppressed through engagement in ED behaviors. In other words, patients with EDs may be more sensitive to potential negative consequences of anxiety and turn to ED behaviors in orders to avoid such consequences.

ED symptoms

· are behavioral attempts to influence, change, or control painful emotional states” & function to regulate affect/provide momentary relief from aversive emotions · Therefore recovery requires experiential challenge (doing things that have been habitually avoided) and reducing avoidance strategies

ED Treatment: Where Do We Begin?

- Severe Malnutrition - Sexual Abuse - Bingeing - Purging - Substance Abuse - Low motivation - Self Harm - Parental Alienation - Suicidal - Anxiety - Depression - PTSD - Chronic - Unstable - Impulsive - Cognitive Impairment - Social Isolation - Medical Complications - Parental Enmeshment - unemployable

ED Trends

We’re seeing earlier onset with a more acute medical presentation. We’re also seeing members of the trans-community; gender dysphoria can fuel poor body image that is managed with ED behaviors.

Ego-dystonic: Motivation

Behaviors/thoughts go against will, not aligned with beliefs and feel intrusive, desire to change.

Ego-syntonic: Motivation

Behaviors/thoughts align with personal values & goals, in harmony with self-image, no guilt

Emotion Awareness Training

Help patients cultivate an increased awareness to their emotional experiences intentionally in a non-judgmental way: 1. Build awareness of emotional experiences in context, as they are happening right now 2. Reactions often rooted in perceived past failures/future threats and uncertainties 3. Distinction between primary and secondary emotional responses “Emotions about emotions” 4. Teach the consequences of judgment-laden attention

Emotion Awareness Training: Importance

· Reactions are often rooted in past failures/future uncertainties, not in the present context of what is acutally happening · “Emotions about emotions” (or secondary emotional reactions) - These reactions carry with them a critical, judgmental tone = “this feeling is bad” · When judgments are placed on emotional experiences, the person often loses touch with what purpose the primary emotion is intended to serve.

Exposure therapy

Necessary to get out of behavior pattern despite discomfort Must manage patient expectations and explain rationale

Exposure therapy: Suffering

- Evidence to suggest that building tolerance to uncomfortable sensations promotes change in individuals with Eating Disorders. - Patient understanding of the rationale and willingness to experience the discomfort is essential!

FBT aka Maudsley Approach

usually 15-20 sessions over the course of 12 months. It is a type of family therapy for the tx of AN devised by Christopher Dare and colleagues at Maudsley Hospital in London. Parents take an active and positive role in restoring weight. Intensive outpatient program intended to avoid hospitalization. Phase I: weight restoration. Phase II: Returning control over eating over to the adolescent, and Phase III: Establishing healthy adolescent identity

Food exposure therapy

is based on the observation of similarities between AN and OCD. People with AN are afraid of food, avoid food, and have ritualized or other abnormal safety behaviors to manage those fears. They have an irrational—highly exaggerated—fear of the effect of food on their shape and weight, and avoid sufficient caloric intake. They show a variety of abnormal behaviors around eating, similar to OCD, such as eating foods in a particular order, chewing slowly, cutting up foods—so like OCD, they have repetitive behaviors used to decrease anxiety about eating. In Joanna Steinglass’s important work on food exposure and response prevention she has used the best possible behavioral therapy practices to help women with AN overcome fear of food. They create a hierarch of the feared situations together, and then gradually expose the patient to the anxiety-provoking eating situations, without safety behaviors.

Food Exposures

- Food = Stimulus - Exposure to food and associated emotions while refraining from avoidance & EDBs Examine - Safety behaviors/rituals - Ingesting particular binge foods - Resisting urges - Eating in a specific way

Food Insecurity: BED

Participants with the highest level of food insecurity (i.e., adults who reported having hungry children in their household) also endorsed significantly higher levels of binge eating, overall ED pathology, any-reason dietary restraint, weight self-stigma, and worry compared to participants with lower levels of food insecurity

Genetic Risk Factors

Genetic: If 1st or 2nd degree relative has Anorexia a daughter is 12X more likely to develop an eating disorder (2nd degree relative has ¼ of genes like an aunt of an uncle). If 1st or 2nd degree relative has Bulimia a daughter is 4X more likely to develop an eating disorder

Genetics in ED

- Research indicates that AN and BN are as inheritable as other serious psychiatric illnesses - There are no single gene explanations although genetics probably contribute to a heightened risk for developing these illnesses - Increased risk with family history of eating disorders, mood disorders, anxiety disorders--(Anorexia -12X and Bulimia -4X) - Many of the personality characteristics of people with AN and BN seem to have a genetic component

How bulimia affects your body

Brain depression, fear of gaining weight, anxiety, dizziness, shame, low self-esteem Cheeks swelling Mouth cavities, tooth enamel erosion, gum disease, teeth sensitive to hot and cold foods Throat & Esophagus sore, irritated, can rupture, blood in vomit Muscles fatigue Stomach ulcers, pain, can rupture, delayed emptying Skin abrasion of knuckles, dry skin Hormones irregular or absent period Intestines constipation, irregular bowel movements (IBS), bloating, diarrhea, abdominal cramping Body Fluids dehydration, low potassium, low sodium Blood anemia Heart irregular heart beat, heart muscle weakened, heart failure, low pulse and blood pressure

Interoceptive Exposure

- Exercise designed to build tolerance of uncomfortable physical sensations

Interpersonal Psychotherapy

It is incumbent upon the therapist in the treatment to quickly establish a therapeutic alliance with positive countertransference of warmth, empathy, affective attunement and positive regard for encouraging a positive transferential relationship, from which the patient is able to seek help from the therapist despite resistance. It is primarily used as a short-term therapy completed in 12–16 weeks, but it has also been used as a maintenance therapy for patients with recurrent depression.

Levels of Care: When to Step Up?

- Medical Status - Suicidality - Weight as percentage of IBW - Motivation to recover - Co-occurring disorders - Structure needed for eating/gaining weight - Ability to control compulsive exercising

Medical Status Criteria: Step up

- OP/IOP/PHP - Medically stable to the extent that more extensive medical monitoring is not required (e.g. NG tube feedings, IV fluids, multiple daily lab tests needed)

Mindfully Observing Patterns

· Antecedents/Triggers = Immediate, Earlier · Response = Thoughts, Bodily Sensations, Behaviors/Urges · Outcome = Short term, Long term

Mindfully Observing Patterns: Purpose

· Your pt can work on anchoring in the present in and out of session. They will begin to keep track of their emotional patterns at home…which include uncovering the triggers of their binge eating, the function of the binge eating behavior, and the short term and long term outcomes…i.e. what is positively or negatively reinforcing the behavior? A side effect of these homework assignments can be a reduction in shame, as they begin to understand the very natural reasons why they repeat these ego-dystonic binge behavior. · This is how, over time, you and your pt will begin to discover what they’re avoiding, escaping, or dampening…. · What’s the “pay-off” of the bingeing? What is it doing for them? What is it that seems emotionally intolerable? · By pinpointing the emotional avoidance, you can design individualized exposures to improve your pt’s distress tolerance and emotional self-efficacy.

Motivation to Recover Criteria: Step up

- OP/IOP: Fair-to-good motivation - PHP: Cooperative, but preoccupied with intrusive, repetitive thoughts more than 3 hours per day* - RES: Poor-to-fair, and preoccupied with intrusive, repetitive thoughts 4–6 hours per day* - Inpatient: Very poor motivation. Uncooperative with treatment or only cooperative in highly structured environment. - *Thoughts can be ego-syntonic or ego-dystonic

Multidisciplinary RES Team

PATIENT at the center - Therapist = OP therapists/previous therapists and other support persons can be part of the “team” - Nutritionist - Psychiatrist - Aftercare - Nurses - Nurse Practitioner - Art & Movement Therapist

Origin ED

· Not one cause- complicated disorders that can result from the “perfect storm” of cultural, psychological, social, emotional, neurobiological, and genetic factors.

OSFED Purpose

person doesn’t fully meet criteria of other eating disorder , but you know there is a problem Most commonly diagnosed because not fully meet other criteria

Past stereotype

Once thought to be a disorder of an “urban/suburban white girl”.

Psychological Comorbidity

- Mood Disorders - Anxiety Disorders - Trauma and PTSD - Substance Abuse - Learning Disorders/ADHD - Personality Disorders - Autism Spectrum Disorder - Gender Dysphoria

Psychological Risk Factors

Low self esteem, Difficulties with emotional expression, Impulsivity, mood dysregulation Strong feelings of inferiority, Fear of maturity, Interpersonal disconnection, loneliness Perfectionism, Emotional, physical and/or sexual trauma.

Psychological Risk Factors

- Low self esteem - Difficulties with emotional expression - Impulsivity, mood dysregulation - Strong feelings of inferiority - Fear of maturity - Interpersonal disconnection, loneliness - Perfectionism - Emotional, physical and/or sexual trauma - Body Image Disturbance

Reasons for Avoidance (ARFID Subtypes)

• 5 Subtypes: 1. Sensory Food Avoidance: Texture- slimy, soggy, crunchy, multi-textures, temp of foods, color of foods 2. Behavioral or Anxiety Based Food Avoidance: Emotional Disturbances related to food- trauma 3. Fear Based Food Avoidance: Eating related Adverse events- fear of choking, gagging, vomiting 4. Temperament Based Food Avoidance: Low interest in food, preoccupied, poor appetite awareness 5. Medical Symptom Related Food Avoidance: GI disorders, food allergies

Risk Factors & Triggers

- Genetics - Psychological Risk Factors - Cultural Influences - Neurochemistry - Weight/body focused sports - Relational influences/peer groups/bullying - Biology - Chronic Illnesses (e.g., allergies, diabetes, cancer, unintentional weight loss) - Other Triggers (e.g., pregnancy/postpartum, dieting, loss, change/transition, trauma, isolation, etc.)

Sociocultural: Dieting as Disease

- When the alleged “cure” is always weight loss, dieting becomes the disease. - An effective, safe, and permanent long term weight loss intervention does not currently exist. - There is mounting evidence that the stress of chronic dieting, weight cycling, and weight stigma/discrimination cause tremendous harm both physically and psychologically.

Sociocultural: Female

- Being Female - Exposure to female beauty ideal of extreme thinness - Objectification of the female body—internalization of the beauty ideal - Perceived discrepancy between self and the beauty ideal - Belief that dieting enhances well-being - It is difficult to recover in a culture that glorifies thinness and is fat phobic

Sociocultural: Female Pressures

· Being female is a risk factor for eating disorders · This is what the media portrays as images of beauty; however, the “real truth” is quite different … · “There is not single cause of body dissatisfaction or disordered eating, however research is increasingly clear that media does contribute and that exposure to and pressure exerted by the media increases body dissatisfaction and disordered eating” (NEDA, 2019) · Losing the weight is never enough

Sociocultural: Food Insecurity

Significantly higher levels: - Binge Eating - Overall ED Pathology - Dietary Restraint - Weight Self-Stigma - Worry

Sociocultural: Impact of Social Media

- Links Between Social Media Use and: - Body dissatisfaction - Drive for Thinness - Disordered Eating - Eating Concerns - Anxiety - Depression

Sociocultural: Life Experiences

- Peer groups with unhealthy behaviors - Extreme dieting or exercise - Use of drugs & alcohol - Self-harm behaviors - History of being teased or ridiculed - Particularly for weight/appearance - Accumulative life stressors and transitions - Parental divorce, frequent moves, rape/incest trauma - Situational pursuits that emphasize specific body-type/weight - e.g. diving, gymnastics, wrestling, ballet - Chronic Illness - GI issues, Type 1 Diabetes, cancer

Sociocultural: Weight Stigma

- Discrimination or stereotyping based on a person’s size. Weight stigma also manifests in fatphobia (the dislike or fear of being or becoming fat).

Structure Needed to Eat or Gain Weight: Step Up

- OP/IOP: Client is able to meet weight goals on their own. - PHP: Client needs some structure to meet weight goals. - RES: Needs supervision at meals, or client will engage in ED symptoms. - IP: Needs supervision during or after all meals or is on a special feeding modality.

Suicidality Risk Criteria: Step up

- OP/IOP/PHP - Consider level of risk. Is residential monitoring needed to ensure safety? - Specific plan with intent requires IP hospitalization

Systemic Issues at the Root

- Diet Culture - Wellness Culture - Fatphobia - The “Thin Ideal” - Weight Discrimination & Weight Stigma - Healthism, racism, homophobia, transphobia, ageism, ableism, white supremacy, classism, etc. - Provider biases, lack of awareness & education

The Avoidance Problem

- Emotions themselves are not unsafe, dangerous or threatening - Attempts to avoid uncomfortable and painful emotional experiences drives unsafe, threatening and dangerous behavior (symptom use).

The Continuum of Care

Can go up or down continuum - Residential: Acute treatment on-site with 24x7 nursing care - DTLA: graduated step down with on-site accommodation for pts at high risk of relapse - PHP: graduated step down for pts at high risk of relapse - IOP: intensive outpatient program - OP Services: individual and/or group - Ability to step-down to other sites in home area for continuity of care

The Dangerous Reality of EDs

- In your lifetime, at least 50,000 individuals will die as a direct result of their eating disorder.

The Good News…

- Complete recovery is possible! - The majority of well-treated patients get better. - Early detection and initial intensity of treatment can help. - Experienced specialists improve outcome. - Results should begin quickly but complete recovery sometimes takes years.

The Harmful Effects of Weight Stigma

- Weight stigma poses a significant threat to mental & physical health. Studies suggest it is a significant risk factor for depression, low self-esteem, and body dissatisfaction. - 79% of weight-loss program participants reported coping with weight stigma by eating more food. - Those who experience weight-based stigmatization engage in more frequent binge eating, are at increased risk for ED symptoms, and are more likely to have a diagnosis of BED.

Tips to Share with Kids

- No food is "good" or "bad” - Listen and honor your body’s cues - Find joyful ways to move your body - People of all shapes and sizes should be accepted and respected - Teasing hurts. Don't take part in it, especially if it is about a person’s appearance - Remember that fat does not equal “unhealthy” and thin does not equal “healthy”.