Eating Disorders
What are your ideas about eating disorders? When you hear that phrase, what comes to mind? What you think of, you'll just take a moment of maybe people you know, loved ones or you yourself if you struggle with an eating disorder. I think in the culture at large, there are a lot of misperceptions about who has eating disorders, so one of the first things I wanted to do was kind of dispel some of those myths.
So, the first myth is that eating disorders only effect women. When actually in fact, there are a lot of men that are effected with eating disorders. You'll see later on, AN stands for anorexia, BN is bulimia nervosa and BED is binge eating disorder. So there's a lifetime prevalence statistic for you as well as you know, at a given point in time. So currently men represent about 25% of the population with anorexia or bulimia as well as 36% binge eating. So certainly keeping in mind, who can be effected by eating disorders which includes men or women.
The next one is that eating disorders are not serious. I hear often working with teens and families that, "Oh it's a phase, they'll get over it, it's not a big deal," when in fact anorexia's the deadliest psychiatric disorder, it has 6 times the mortality rate compared to general public. A lot people think of things like schizophrenia, depression, bi-polar disorder as being the most lethal, the deadliest when in fact anorexia is the deadliest of the psychiatric disorders and one of the things that we go through that we talk about, is why that is.
But that's certainly a myth that it's not that serious or doesn't need to be taken seriously or treatment isn't as important. So again, part of it is the medical complications and part of it is by suicide. The longer someone has an eating disorder, the more likely it is to kill them so over time ... That's one reason why I actually really enjoy working with youth is that's often the age of onset, so in some ways if you're able to treat youth younger with eating disorders then it may not continue for their entire life. Some people struggle with it their entire life.
Another myth is you can tell whether someone has an eating disorder just by looking at them. Are they overweight? Are they underweight? Things like that when in fact, most people, especially with bulimia may fluctuate around a healthy weight. So they may only gain or lose a certain amount of ... Certain percent of their weight so they're technically within a healthy range or maybe a little bit overweight, when in fact if you think about all the time and the effort that goes into maintaining bulimia, it can be very stressful.
The other thing is people with anorexia may do things to compensate. They may wear big sweatshirts, they may wear baggy clothing, they may kind of wear certain layers and things that kind of give you the impression they haven't lost that much weight. As well as with binge eating, they may be binge eating but they may not be morbidly obese, so you definitely cannot tell whether someone has an eating disorder by looking at them so it's better you know, through this webinar we'll talk about ways to assess as well as getting a little bit into treatment.
So another myth, again I think this is common with teenagers but it can happen at any age for any population that it's used to get attention. Eating disorders are only used to get attention. There's a really high co-occurrence rate and I gave you a link there that you can follow up for a great website eatingdisorderhope.com that talks about the height incidents with other mental health issues.
In my clinical practice as Fawn mentioned, in my practice I'm a licensed marriage family therapist, so the clients I see I rarely see eating disorders on their own, they're typically co-occurring with something else, whether it's depression, anxiety, PTSD, OCD, things like that. So, they're in my opinion not used to get attention, there's often serious medical and psychological ramifications. Things that people wouldn't necessarily choose just to get attention.
First I wanted to go over the DSM criteria, some of you may be already familiar with the DSM-5 and also the correlation with the ICD-10. But I wanted to just briefly go over it, one note on my slides, there's a lot of information on them so we may not go over every slide in depth but I wanted to make sure you had the info, so don't worry if I'm skipping things I just want to make sure you had the information.
So, for the first ... For the main 3 categories within the DSM-5 is the anorexia nervosa, bulimia nervosa and overeating associated with other psychological disturbances, often called binge eating disorder or BED and then there is an eating disorder unspecified. So for example, if someone doesn't meet criteria for time frame or if you need additional information, maybe it's the first time you've seen someone and the mental health professional needs more time to fully establish a diagnosis.
So the first one that we'll talk about is anorexia nervosa. Essentially with anorexia is it's a significantly low weight. One interesting difference that was a change to the DSM-5 from DSM-4 was they actually took out the criteria that you have to have amenorrhea or loss of period in women or be 15% ideal body mass index. That is still in the ICD-10 criteria thought, so keep in mind one has it and one doesn't. But either way it does have to be significantly low weight, as ... Sorry, less the minimally normal or for children less than expected so if they're not growing at the rate that they should be. There also is associates an intense fear of gaining weight or becoming fat, so persistent behavior that interferes with weight gain, even though it's a significantly low weight. So even if they're low weight, they look in the mirror, they still see themselves as fat. So that kind of distortion that occurs.
There's also a disturbance in the way one's body weight or shape is experienced, or undo influence a body weight or shape on self-evaluation or being unable to recognize, so that's similar to what I was talking about where they may look in the mirror and not see what's in front of them, they might see a different version of themselves. Part of what we think that has to do with, there's a lot of research into mirror neurons, so essentially one of the ways we communicate is that we become aware ... We have mirror neurons, so that's how we mirror things like empathy and that's how we mirror things ... You know we can kind of see reality, they think that people with anorexia have less ... Have fewer mirror neurons and so they actually physically aren't seeing themselves accurately. It's not that they're arguing with you, it's not that they're lying with you, they physically cannot see themselves the way that we see them.
So, typically between the half and 1% of American women suffer from anorexia as a whole, you do need to specify ... And if you're not the one diagnosing, it's helpful to be familiar with diagnosing, you do need to specify if it's restricting type, if it's binge eating and purging because they're typically ... In anorexia there has to be some type of compensatory behavior, so purging is anything that includes self-induced vomiting, misuse of laxatives, diuretics or enemas. I think the most common that I see is vomiting, I don't think laxatives, diuretics or enemas are as common, especially with youth. Or you can have weight loss through dieting, fasting or excessive exercise so we'll talk a little bit later about how to assess for some of those things.
They either have restricting, which means that they do recurrent episodes or binge eating. So that means they're overeating and then purging. Then A-typical means it's ... One of the main features of anorexia is missing, so maybe the amenorrhea or maybe it's not significant relapse.
So, one thing to keep in mind that the DSM-4, sorry the DSM-5 does use is the BMI so it's important that when working with people with anorexia that you work with medical professionals all along the way with any eating disorder, but especially helpful that the medical professional is the one calculating the BMI, because there can be a lot of nuances in it. So for example, some of my clients will tell me what their height is but then they'll go see our psychiatrist and they might be off an inch or two, well that can actually throw your BMI off if it's an inch or two. Also, I'm not a medical professional, so I am definitely not responsible for weighing my clients but I definitely coordinate with the psychiatrist and the pediatricians and medical doctors I work with.
I do like to ask clients though, especially in initial assessments, a bit about their weight. Especially if there's any indications that it's been a problem for them. You may find certain traits such as obsessiveness, so for example if they could list off their weight from you know, age 10-20 they know every year, or every significant event they know their weight. That to me would indicate a certain level of obsessiveness, may be likely also an eating disorder going on but I do think it's helpful, you do have to have a medical professional to gather the BMI.
So I have this kind of rough calculation provided to me in a webinar, I'm sorry in a training that talked about kind of a snapshot healthy average range. That's not saying if you're over or under that is unhealthy but if you're working with clients if you're, you know the one responsible for gathering assessment information and they are 5 foot tall and they say, "Oh yeah, I'm 90 pounds," you might immediately have some alarm bells go off and say, "Okay, let me ask a couple more questions," so she gave me this, one of the trainers gave me this for 5 feet roughly 100 pounds, 5'1", so for every inch you add 5 pounds, so 5'1" would be 105. That doesn't directly correlate exactly because BMI has ranges, but I think it's a helpful thing to keep in mind so if there's a huge risk, you can maybe assess a little bit more right from the get go.
The next slide talks about bulimia, so the difference ... The one thing with bulimia is it does include binge eating, so binge eating includes both of these. Eating in a discreet period of time, so for example in a small window, an amount of food that is larger than what most people would eat. A sense of lack of control over eating, so for example you know these are not our clients that are bingeing on carrots, or celery, it's often high calorie, high fat, high sugar or salt food. So ice cream, you know chips, fast food, things like that and it's a large amount of food. So I will clients, "What do you consider a binge?" I had one client who actually had anorexia who considered a chipotle burrito bowl a binge. Well yeah, it might be a large amount of food but that certainly is not a binge, that's a socially acceptable amount of food. But she considered that you know, one burrito bowl was a binge.
So it's helpful to ask what they mean by that. Bulimia does include recurrent, inappropriate compensatory behavior, so things like vomiting, diuretics, fasting or excessive exercise. This is the big difference between this disorder bulimia and the next one we're going to talk about is binge eating. So in bulimia you do have the compensatory, you have some kind of behavior to try to you know, undo that weight gain or to experience shame or guilt, when that happens.
So in order to meet criteria for bulimia, has to happen at least once a week for 3 months and then self evaluation is influenced by body shape or weight. Some people do ... Some clients do swing on a pendulum, they might be first diagnosed with anorexia then they swing to bulimia, then swing back, so it's not uncommon to see certain people diagnosed, depending on the time of their life and their behaviors, with more than one eating disorder.
So bulimia is a bit more common than anorexia, it's 1-2% of adolescent and young women. There are some specifications there, if you look down at the extreme, average of 14 or more episodes per week. If you think about the amount of time that goes in for a client to ... Or for any person to have a binge eating and then a compensatory ... Exercise for example, or fasting or purging, 14 times a week is about an average of 2 times a day for the extreme category. So that's a lot of time that goes into these behaviors, it often takes over other areas of life school, work, social. If we think about social relationships, a lot of times what you're doing is you're getting together with friends or family to eat a meal, so there's a lot of things that people with eating disorders can't participate or choose not to participate with because it's a difficult experience for them, so that can lead to social isolation and other things.
The next category is binge eating disorder, so this is actually new for DSM-5, this is not in previously and I think it's really helpful that it's in there, so that this population can get treatment. You'll see in the next slide it's actually the most frequently occurring. So you do have ... For binge eating, you have recurrent episodes of binge eating, which we talked about and then these are associated with 3 or more of the following: eating more rapidly than normal, eating until uncomfortably full, eating large amounts of food when not actually physically hungry, eating alone due to embarrassment how much one is eating and feeling disgusted with oneself, depressed or guilty.
