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BED7787 - Binge Eating Disorder: An Introductory Guide

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BINGE EATING DISORDER: AN INTRODUCTORY GUIDE

by Iréné E. Celcer, MA, LCSW


Iréné Celcer, LCSW is a Licensed Clinical Social Worker with over twenty years experience working with eating disordered patients. She is a member of the Board of EDIN (Eating Disorders Informational Network), an organization based in Atlanta whose mission is to educate and prevent eating disorders, and the author of two books and numerous articles. Additionally, Ms. Celcer has delivered a number of workshops and presentations to other clinicians and the public on the subject of anorexia nervosa, bulimia nervosa and binge eating disorder. She has appeared in numerous TV programs in the USA and abroad.

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Course length

7 contact hours: core clinical

OBJECTIVES

The objective of this course is to provide the healthcare professional with a comprehensive introductory overview of Binge Eating Disorder (BED). When the trainee completes this course, he/she will:

- Understand the classification and status of BED, according to the DSM-IV
- Understand the similarities and differences between BED, Bulimia Nervosa (BN) and Anorexia Nervosa (AN) according to the DSM-5
- Know the prevalence of binge eating disorder and its incidence among males and females
- Comprehend causes and mechanisms underlying binge eating disorder.
- Know mental disorders commonly associated with and co-morbid with BED
- Learn how to recognize, evaluate and assess for BED
- Discuss ways to interview, assess, motivate, and refer patients for treatment
- Comprehend the different treatment modalities effective in addressing BED, including the appropriate use of medications.

This course is primarily designed for clinicians in the earlier stages of their career, or for more advanced clinicians reviewing basic concepts in this area.

Recommendations for Preparing for the Post-test

Please take special note of the BED factoids. They are designed to provide clinicians with key foundation knowledge about BED.

Important facts and concepts are typically italicized and highlighted in color.

Issues related to successful treatment outcomes are of particular importance and will be emphasized in the test, including statistics related to outcomes.

Factors related to the etiology and development of BED are important for clinicians to understand and will be emphasized in the test.

BED/ED Factoid

Community surveys have estimated that between 2 percent and 5 percent of Americans experience binge-eating disorder in a 6-month period.

Source: NIMH www.nimh.nih.gov/

 

Forward
Section I: Questions and Answers about Binge Eating Disorder
Section 2: Causes and Risk Factors for BED
Section 3: Examination of the Socio-cultural Aspects of BED
Section 4: Intervention with the Eating Disordered Patient
Section 5: The Treatment Process
Section 6: Additional Issues in Treatment: Fear of Fat and Cultural Pressure
Section 7: Hands-On Exercises for Patients suffering from BN, AN, ED-NOS and Body Image Problems

References and Test

 

 

 

Forward

Most clinicians who work with individuals, couples or families will be confronted at some point in time with one or more clients whose problem may be - or may include - the symptoms and behaviors of BED. This disorder falls into the larger diagnostic category of Eating and Feeding Disorders within the context of the DSM-5. Sometimes, such clients may be referred by an internist, an endocrinologist, or a gastroenterologist trying to help the client get a handle on their weight and health issues.

In other instances, the client may present with some other kind of health problem and the BED may be uncovered in the course of the treatment. As we will see, there is a sizeable amount of correlation between BED and depression, among other health problems.

Because there is a certain measure of shame attached to BED, it may be more comfortable for some clients to underplay or hide that component of their difficulties – at least until the treatment relationship feels a little safer. By that point in time, though, the relationship may be well enough established that a transfer to a BED specialist may create a difficult transition for the client.

In such instances the clinician will be asked to determine whether the need for a BED specialist is compelling enough to warrant the disruption of the established relationship, or whether the clinician can bring sufficient knowledge about BED to the treatment that the patient's needs can be successfully addressed.

There will be two groups of clinicians for whom this course will be appropriate. The first group is the larger group: those clinicians who will not necessarily become BED specialists, but who will need a solid foundation in the nature, course and treatment of BED in order to possess both skill and knowledge when a patient with BED appears as part of their practice.

Because this represents the more usual circumstance, the course will have as its focus providing this target group with the most useful information possible.

For this group of trainees, this course does not pretend to serve as a comprehensive training of the sort that would allow a clinician subsequently to present himself or herself as a specialist and expert in the treatment of Binge Eating Disorder. Rather, it will provide a solid foundation for knowing how to proceed with such cases when they arrive on the clinician's doorstep. This knowledge base – for the non-specialist – may need to include how to make successful referrals to clinicians who do specialize in BED.

The second – and smaller - group will consist of those clinicians who may indeed wish to become eating disorder specialists, but who are just at the beginning phases of preparing themselves for that path. The hope is that this training course will also provide for them a solid and detailed foundation for their professional journey, with some direction about other areas of study that may be required on the way to achieve expertise in this kind of work.

There are a number of basic facts about BED that both groups of trainees must understand.

There are a number of basic facts about BED that both groups of trainees must understand. For instance, there has not been complete agreement within the mental health and medical communities concerning whether BED is a separate nosological entity, or a subgroup of Bulimia Nervosa non-purging type. With the publication of the DSM-5, the representation of BED as a new and separate diagnostic category has to some degree attempted to settle this disagreement, but some clinicians are still not in agreement.

Another basic piece of knowledge that both groups of trainees need to know is that some researchers believe that BED cannot be accurately described as a behavioral subtype of obesity, either. Certain researchers take this position for a very specific reason. Successful treatment for binge eating does not seem to result in a significant weight loss for obese patients. This fact tends to undercut the supposition that BED is best described as a subtype of obesity. (22)

Currently there is at least one study that views four models with which some researchers and clinicians conceptualize BED. Each of the models seems to have some aspects that have been validated, and therefore each model contributes to the understanding of BED. Each model however, also has flaws and components that seem to be disconfirmed in the understanding of BED. (22)

The models in question are:

Model 1) BED as a Distinct Eating disorder
Model 2) BED as a variant of Bulimia Nervosa
Model 3) BED as a subtype of behavior of obesity
Model 4) BED as an associated feature of another primary psychological disorder (22)


We will see how this issue and these models play themselves out in the understanding and treatment of BED in the next several years as the DSM-5 is fully adopted and critically examined. In addition to keeping track of these four models, it will also be helpful to examine the cluster of symptoms from which most BED patients suffer. The cluster of symptoms consists of: obesity, body image distress and psychopathology, especially depression. (22)

Apart from the diagnostic questions, both the models and the symptom clusters will be considered part of the foundation base of knowledge concerning BED. This overall knowledge base will need to be fairly broad, as many aspects of this knowledge base will have an impact on whether the clinician can successfully perform his or her key role at the point of initial contact - inviting the patient into accepting treatment services.

The clinician must first have sufficient awareness to determine if BED is present (even if the patient does not volunteer all the pertinent information). This will require a substantial amount of knowledge of what to look for and how the symptoms will present themselves. Very importantly, it will also demand that the clinician put aside any preconceived ideas about how obese people eat.

The clinician must then have knowledge of what forces are operating in the patient's overall symptomatology. In order to circumvent the patient's resistance to acknowledging the problem (i.e., many BED feel ashamed of their behavior and looks), the clinician must be prepared to address each factor that contributes to binge eating at the level at which it is operating in the patient - without blaming him or her.

Next, the clinician must have a reasonable overview of what approaches are used by specialists to intervene with BED. If the clinician is going to incorporate this knowledge into the treatment plan, there must be a solid enough foundation to work with some competence. Conversely, if the clinician is going to be successful in referring a generally resistant patient - or a patient who is in distress - to a BED specialist, that clinician must have sufficient knowledge to answer the patient's questions about what treatment with the BED specialist will entail.

It is vital for the clinician interviewing a patient suffering from BED to be prepared to intervene with knowledge and skill if these patients arrive for treatment. For this reason, two sections will be presented concerning treatment.

One of the sections will provide an overview of treatment models used to address BED. The other section will present some information about interactional styles that may be used by BED specialists, as well as intervention content and how it is used. This will allow the non-specialist to both answer pertinent questions of what awaits the patient and to align the initial assessment interventions with the broader scope of treatment.

This course has been developed to provide the fundamental knowledge base that will also allow a clinician to review the latest research on BED and operate with some confidence and competence.

Some sections, like those covering recent statistics on incidence and prevalence, are designed to provide the clinician with important overview information that may correct common misperceptions in the field.

Other sections, like those covering socio-cultural factors contributing to the BED - such as life stressors, genetics, family dynamics and socio cultural forces - will be useful in shaping the dialogue with the patient when it comes to building motivation for change. Still other sections will cover more concrete skills that will be useful in identifying and responding to BED.

The common thread throughout is that each section has been composed with an eye towards offering the most complete and useful information for the clinician. Every attempt has been made to be as brief as possible, while including all of the substantial information necessary to provide a comprehensive overview.

As a point of entry, we will present a number of summary sheets addressing each of the different diagnoses addressed in the section on eating and feeding disorders. These summary sheets will provide a quick overview of each of the diagnoses in this category. This material will then be expanded upon in ways that will provide a more detailed overview of the subject matter.


                    Eating and Feeding Disorders Summary Sheets

Binge Eating Disorder Summary Page

DSM-5 Code:       F50.8 Binge Eating Disorder

Common Specifiers:
• In partial remission
• In full remission
• Severity Level
• Mild
• Moderate
• Severe
• Extreme

Etiology of Binge Eating Disorder: The exact causes of Binge Eating Disorder are not fully understood, however, there are a variety of factors that are thought to influence the development of this disorder. These factors include biological abnormalities that may contribute to compulsive eating and food addiction. It is also believed that a number of psychological factors may contribute to the development of this disorder, including depression, low self-esteem, body dissatisfaction and shame associated with being overweight, and difficulties managing distressing affective material. A history of trauma, particularly in childhood, or neglectful and/or hostile parenting approaches when the patient is a child, can also increase the likelihood of developing BED. A history of being sexually abused is a traumatic experience that also has shown some correlations with the development of BED. Social pressures to be thin – combined with social condemnation and body shame or criticism for being overweight - may also contribute to the development of this disorder. A history of dieting or attempts at dieting may also be a contributing factor. There are also metabolic and hormonal changes that occur within the body when weight is gained that may contribute to difficulties in controlling appetite, as levels of the appetite increasing hormone, ghrelin, and the satiation created hormone, leptin, among other physiological events, are altered in complex ways with the accumulation of fat cells in the body. BED may be held in place by a complex, self-propagating cycle of affective distress, leading to binge eating to create comfort and relief, followed by shame, guilt, self-disgust, and despair over the loss of control over eating, leading to additional affective distress that further propagates the cycle.

Prevalence: According to the NIH, the lifetime prevalence of Binge Eating Disorder is approximately 2.8% for US adults.

Clinical Manifestations: Primary manifestations of BED include a loss of control over eating behaviors during episodes of bingeing where unusually large quantities of food are ingested, often in a rushed, almost frantic manner, accompanied by a momentary feeling of relief from stress in conjunction with a kind of emotional numbing, and followed by a subsequent movement towards regret, disgust with self, and other negative feeling states. This is often followed by efforts to regain control over the binge eating episodes and address the excessive calorie intake through efforts at dieting. Ongoing binge eating disorder usually results in weight gain up to and including obesity, triggering complex metabolic and hormonal changes as the body increases the number and size of fat cells.

Best Practices Diagnostic Approaches: An accurate diagnosis of this disorder will generally require gathering a thorough history of the client, including a detailed history of eating and nutritional habits, perceptions and values about food, eating, and body image, and any history of dieting approaches. Because there may be hereditary factors involved in this disorder, it is also recommended that a family history of problems with eating disorders, impulse control disorders, and/or and compulsive disorders be taken. There is also a very high level of comorbidity with substance abuse, so a detailed history of substance abuse should be gathered. Additional history to be taken includes developmental milestones and when they were reached, history of the birth mother prenatally and during the pregnancy, a history of nutritional deficiencies, any illnesses, injuries or exposures to toxic substances that may have been experienced by the mother during pregnancy or the child at any time, and a family history of disturbances, trauma, attachment disruptions, and mental health conditions that may have contributed to the disorder. There are also assessment tools that may be utilized, including a self-report questionnaire, such as the SCOFF questionnaire, or something slightly more formal, such as the Eating Disorders Examination-Questionnaire (EDEQ). Because there are numerous medical conditions that may be created from bingeing behaviors, a full medical examination is recommended. This assessment would be conducted by a health professional with specialization in addressing eating disorders, and would include a thorough medical assessment, including test to determine problems with blood sugar, metabolite imbalance, and other medical assays that would determine level of severity and safety risks. Given that the prevalence of Borderline Personality Disorder is higher in patients with BED than in the population at large, there is some comorbidity between these two disorders. Accordingly, a thorough assessment process should be prepared to assess for signs of BPD and to gather information about any risk of suicidal intentions.

Best Practices Treatment Approaches: Treatment approaches for Binge Eating Disorder will typically begin with some combination of Cognitive Behavioral Therapy, Interpersonal Therapy, and/or Dialectical Behavioral Therapy. This may be supplemented by the use of a Relapse Prevention Plan, a tool that has been used successfully with addictive disorders. The goal of the relapse prevention plan is to identify triggers for relapse into problematic behaviors and develop a plan to prevent the triggers from turning into active pathologies. A referral to psychiatrist who specializes in eating disorders may be helpful, as the FDA has recently approved one medication specifically for use with this disorder, Vyvanse. SSRI medications may also be helpful in certain cases, and Topamax has shown some capacity to reduce bingeing behaviors. Treatment may also consist of addressing some of the underlying risk factors that contribute to the development of BED: low self-esteem, difficulty managing negative emotions, impulse control problems, and residual effects of traumas, poor parenting, and comorbid psychological problems that often accompany this disorder. Patients with BED may have concurrent obesity related medical conditions, such as diabetes and cardiovascular problems, and these must be treated medically. Binge Eating Disorder is also often associated with depression, borderline personality disorder, substance abuse, self-injury, and a troubled family life, and effective treatment will address these other complications, as appropriate. Severely obese patients who suffer from Binge Eating Disorder may also be candidates for gastric bypass surgery to lose weight and interrupt the binge-shame-distress- binge cycle that can accompany this disease. Research indicates that this may provide a 2-3 year window of reduced weight in which they can develop more effective strategies for treating the central causes of the disorder while shame around body size is reduced and hopefulness is increased. Research is also suggesting that some variations of gastric surgery may also remove cells that create distortions to the ghrelin-leptin based homeostatic balance, leading to reductions in the neurochemical messages that create physiologically-driven pressures to eat.

Other Conditions to Rule Out: This disorder must be distinguished from Anorexia Nervosa, purging type, the key differentiating feature being the extreme fear of weight gain predominating in Anorexia, and higher degree of loss of control over eating predominating in BED. In distinguishing BED from Bulimia Nervosa, patients with Bulimia are more likely to maintain a body weight that is within or somewhat above normal parameters for height and age, as opposed to patients with Binge Eating Disorder, whose weight is more likely to be significantly overweight. With Binge Eating Disorder binge eating is interspersed with efforts to control eating and reduce weight through primarily food restrictive behaviors. Bulimia Nervosa tends to present with more rapid and immediate attempts to reverse the effects of a binge by purging or fasting behaviors. There is considerable overlap between these two diagnoses and clients will sometimes transition from one diagnosis to the other in response to internal and external changes. This disorder must also be differentiated from Body Dysmorphic Disorder, the key differentiating feature being that patients with this condition may focus on numerous perceived flaws in their physical appearance, not just their weight and body size. It must be noted that BED may be comorbid with Borderline Personality Disorder. This condition must also be differentiated from anxiety and trauma related disorders where bingeing may be used to relieve symptoms of anxiety and provide nurturance. Variations in appetite may also accompany depressive and mood disorders, so these must be ruled out as well. There are also a number of medical conditions that may cause alterations to a person’s appetite and weight profile, including thyroid disorders, head injuries or illnesses affecting the hypothalamus, and any number of conditions that interact with hunger, eating and digestion, including diabetes. Of particular note is Prader-Willi Syndrome, a genetic disorder that, among other manifestations, produces a constant, almost insatiable sense of hunger that may lead to uncontrollable binges. It is also important to rule out use of substances that may cause fluctuations in normal appetite.

Comments: This disorder should generally not be diagnosed by Master’s level mental health clinicians who do not have specialized skills in diagnosing and treating eating disorders. Furthermore, due to the numerous medical conditions that may accompany BED, it is always recommended that the treatment of this disorder be handled in coordination with other medical professionals who have familiarity with this condition. As a general rule, clients with this condition may require 5-7 years of therapy in order to bring this condition into a state of remission.

Anorexia Nervosa Summary Page

DSM-5 Codes: F50.01       Anorexia Nervosa, Restricting Type
                         F50.02       Anorexia Nervosa, Binge-Eating/Purging Type

Common Specifiers:
• In partial remission
• In full remission
• Severity Level
• Mild
• Moderate
• Severe
• Extreme

Etiology of Anorexia Nervosa: At present no one knows the exact mechanisms or causes underlying eating disorders. There is no solid evidence that a single isolated factor causes an eating disorder. There may be a possible combination of genetic, physiological, nutritional, psychological, familial and cultural aspects of the ailment that make eating disorders complex and multifaceted diseases. Biological vulnerability, genetics, and culture and nurture all seem to play a part in the total picture. Supporting the genetic factors that may contribute, research indicates that first-degree female relatives of patients with anorexia nervosa have higher rates of anorexia nervosa and bulimia nervosa. There are also physiological changes from calorie restriction that likely contribute to the persistence of the eating disorders and the resistance to psychological intervention, through alterations to the brain's chemistry, electrolyte imbalance, low blood sugar, and other physiological changes. These changes may contribute to moodiness, depression and apathy that further affects awareness of and response to hunger signals. From a psychological level, there may also be a profound fear of compulsive eating that contributes to extraordinary efforts at keeping eating under control. Psychodynamic theories posit that patients with anorexia nervosa may have difficulties with separation and autonomy, problems with affect regulation, and anxieties about negotiating psychosexual development, which suggests some disruptions to a healthy parent-child relationship. Family and cultural values and ideals concerning food, eating, and preferences for body image likely also contribute to the emergence of this disorder. This disorder has historically been most likely to emerge at the point of reaching puberty, so the increased stress that occurs during this intense period of change may also play a part in the emergence of this disorder. It is also important to note that childhood sexual abuse histories are reported more often in women with eating disorders than in women from the general population.

Prevalence: Prevalence rates for this disorder are estimated to be between 0.1 and 1.0%, with a rate of about 0.02% for males. Prevalence rates for both sexes have been rising over the past couple of decades.

Clinical Manifestations: Anorexia nervosa is manifested by a refusal to gain or maintain weight at a healthy level (defined as below 85% of normal weight by height and age), driven by an intense fear of and pre-occupation with becoming and being overweight, and distorted thinking and perceptions about one’s own weight and body shape, as well as an undue influence on one’s sense of self-worth if weight is not kept at an acceptable level. This will manifest behaviorally by calorie restriction, fasting, excessive attempts to burn calories through exercise (Restricting Type), or by various kinds of bingeing behaviors to restrict calories by not allowing food to be fully digested (Binge-Eating/Purging Type). There is some research that suggests that many patients with this disorder express heightened levels of obsessiveness, perfectionism, harm avoidance, and elevated levels of anxiety, which may be focused upon issues related to food, eating and body size, shape and image. The psychological components of this disorder intertwine with and support the behavioral aspect of this disorder.

Best Practices Diagnostic Approaches: An accurate diagnosis of this disorder will generally require gathering a thorough history of the client, including a detailed history of eating and nutritional habits, perceptions and values about food, eating, and body image, and a history of weight gain and loss over time. Because there may be hereditary factors involved in this disorder, it is also recommended that a family history of problems with eating disorders and/or obsessive and compulsive disorders be taken. Additional history to be taken includes developmental milestones and when they were reached, history of the birth mother prenatally and during the pregnancy, a history of nutritional deficiencies, any illnesses, injuries or exposures to toxic substances that may have been experienced by the mother during pregnancy or the child at any time, and a family history of genetic conditions that may have contributed to the disorder. There are also assessment tools that may be utilized, including a self-report questionnaire, such as the SCOFF questionnaire, or something slightly more formal, such as the Eating Disorders Examination-Questionnaire (EDEQ). Because there are numerous medical conditions that may be responsible for disruptions in appetite, a referral for a thorough medical examination is always indicated where a dangerous loss of weight is noted. In cases where anorexia may have progressed to the point where there are health and safety risks involved, the client should be referred for additional assessment to determine the need for referral to a more restrictive environment. This assessment would be conducted by a health professional with specialization in addressing eating disorders, and would include a thorough medical assessment, including test to determine problems with blood sugar, metabolite imbalance, and other medical assays that would determine level of severity and safety risks. Because this disorder has such a high rate of mortality, clinicians should err on the side of caution when deciding how soon and how quickly to make a referral for this higher degree of assessment. Inpatient hospitalization is typically considered for adults when their weight is below 75% of normal, and there are either medical or psychiatric complications - or a risk of suicidal intentions, with a plan - that require round the clock medical care and/or supervision.

Best Practices Treatment Approaches: Treatment approaches for Anorexia Nervosa will typically include a number of different components, such as: 1) Individual therapy; 2) Family therapy and/or contact/education; 3) Group therapy and/or peer support; 4) Nutritional/dietary counseling; 5) Medication and medication management. If the client's weight has reached a point where it is potentially threatening to the client's life or health, treatment may include some additional and more intrusive components: 6) Medical supervision; 7) Involuntary feeding. Clients with co-morbid disorders may also receive additional services to target those problems: 8) 12-step support for substance abuse problems; 9) Other supportive services as needed. One of the important building blocks of this process will consist of exploring and increasing the client's internal motivation for change, and Motivational Interviewing approaches may be very helpful in forwarding this process. Individual treatment will generally combine elements from three major schools of thought: psychodynamic, Cognitive Behavioral, and the Disease Addiction model. Two newer approaches are Interpersonal Therapy (IPT) and Ego Oriented Individual Therapy (EOIT). Research also appears to indicate that Family Therapy is an important component of successful treatment, particularly with younger clients who suffer from Anorexia. The use of medication to treat the primary symptoms of Anorexia is not supported by the research, however medication may be a part of the treatment of secondary or comorbid conditions such as depression, OCD, or mood disorders.

Other Conditions to Rule Out: This disorder must be distinguished from Bulimia Nervosa, the key differentiating feature being the extreme fear of weight gain predominating in Anorexia, and a fear of loss of control over eating predominating in Bulimia. Patients with Bulimia are more likely to maintain a body weight that is within or somewhat above normal parameters for height and age. There is considerable overlap between these two diagnoses and clients will sometimes transition from one diagnosis to the other in response to internal and external changes. This disorder must also be differentiated from Avoidant/Restrictive Food Intake Disorder, the key differentiating feature being that patients with this condition lack the distortions to their body image that accompany AN. This disorder must also be differentiated from Body Dysmorphic Disorder, the key differentiating feature being that patients with this condition may focus on numerous perceived flaws in their physical appearance, not just their weight and body size. This disorder must also be differentiated from Obsessive-Compulsive Disorder, the key differentiating feature being that patients with OCD may have numerous areas where behaviors are driving by compulsions, not just those related to eating and feeding. Because there can be considerable overlap between AN and OCD, it must also be considered whether the conditions exist comorbidly. This condition must also be differentiated from anxiety and trauma related disorders where the avoidance of food may be related to reductions in hunger due to the physiological consequences of elevated sympathetic nervous system activity. Loss of appetite may also accompany depressive and mood disorders, so these must be ruled out as well. There are also a number of medical conditions that may cause alterations to a person’s appetite and weight profile, including head injuries, neurological damage from illness, including tumors, HIV, and any number of conditions that interact with hunger, eating and digestion, e.g., Celiac Disease, hyperthyroidism, or conditions affecting the pituitary gland. It is also important to rule out excessive use of stimulants and other substances that interfere with normal appetite. Eating disorders have a high degree of comorbidly with personality disorders, so assessment must consider whether a personality disorder is present as a precursor to AN or comorbidly with AN.

Comments: This disorder should generally not be diagnosed by Master’s level mental health clinicians who do not have specialized skills in diagnosing and treating eating disorders. Furthermore, due to the very high mortality rate of this disorder, due to the numerous medical conditions whose signs and symptoms may be mistaken for AN, and due to the high number of medical conditions that may accompany AN, it is always recommended that the treatment of this disorder be handled with a team of medical and mental health professionals experienced in treating AN working in coordination. This disorder has one of the highest mortality rates of any diagnosis in the DSM, and treatment should only be undertaken by professionals skilled in handling the case responsibilities and having resources available to meet the patient’s medical and psychological needs.


Bulimia Nervosa Summary Page

DSM-5 Codes:        F50.2 Bulimia Nervosa


Common Specifiers:
• In partial remission
• In full remission
• Severity Level
• Mild
• Moderate
• Severe
• Extreme

Etiology of Bulimia Nervosa: At present no one knows the exact mechanisms or causes underlying eating disorders. There is no solid evidence that a single isolated factor causes an eating disorder. There may be a possible combination of genetic, physiological, nutritional, psychological, familial and cultural aspects of the ailment that make eating disorders complex and multifaceted diseases. Biological vulnerability, genetics, and culture and nurture all seem to play a part in the total picture. Supporting the genetic factors that may contribute, research indicates that first-degree female relatives of patients with anorexia nervosa have higher rates of anorexia nervosa and bulimia nervosa. Psychodynamic theories posit that patients with anorexia nervosa may have difficulties with separation and autonomy, problems with affect regulation, and anxieties about negotiating psychosexual development, which suggests some disruptions to a healthy parent-child relationship. Family and cultural values and ideals concerning food, eating, and preferences for body image likely also contribute to the emergence of this disorder. The average age of onset for this disorder is age 18, but it may appear earlier. It is also important to note that childhood sexual abuse histories are reported more often in women with eating disorders than in women from the general population. According to the NIH, risk factors that have been identified as being possible contributors to the development of BN include childhood sexual abuse, male homosexuality, eating alone, living in a sorority house, diabetic poor glycemic control, low self-esteem, dieting, involvement in athletics, and occupations that focus on weight. As in Anorexia, bulimic patients have negative self-evaluations, placing inappropriate importance on weight and body image, a force that contributes to the shame, guilt, and worry about loss of control over eating and concomitant weight gain. According to the NIH, bulimic patients are characterized as extroverted perfectionists who are self-critical, impulsive, and emotionally undercontrolled, with the most at-risk population consisting of single, white, educated, college-aged women. Other risk factors may include difficulty expressing negative emotions, difficulty resolving conflict,

Prevalence: Prevalence rates for this disorder are estimated to be between 2% and 3%, with a higher rate for specific population groups, specifically college age females (up to 10%). Prevalence rates for males are approximately 10% of the rate for females.

Clinical Manifestations: The cardinal symptoms of bulimia nervosa include only inappropriate bingeing and compensatory behavior, not low body weight. A subjective sense of loss of control over eating is a key feature of bulimia nervosa, and the amount of calories consumed is not necessarily the defining standard of what would constitute a binge in the mind of a patient with BN. Subjective binges are defined by a subjective appraisal that more food was eaten than should have been consumed and experienced as a representation in the client’s mind that there is a lack of control. The bingeing behavior is then followed by feelings of guilt and shame, and efforts to undo the calorie consumption through purging actions (purging subtype) or fasting or excessive exercise (non-purging subtype). Bulimic episodes may occur within a somewhat ritualized and potentially rigid pattern that may even follow a pre-determined schedule, with potentially predictable emotional and behavioral elements following a regular sequence. In the pre-binge stage, the bulimic may present with boredom, cravings, anxiety, and depression that sets the emotional preconditions for a bingeing episode. The binge may be followed by post-episode depression and lack of self-control. Bulimics will typically binge in private, and accordingly may plan binges and purges in ways and at times when they can conceal their behavior. In severe cases, bulimics may arrange daily schedules in ways that allow them to be assured of time for bingeing and purging. They may also deprive themselves of food before the binge, and it is thought that this deprivation plays into the ritualistic pattern of bulimic eating.. There is some research that suggests that many patients with this disorder express heightened levels of obsessiveness, perfectionism, harm avoidance, and elevated levels of anxiety, which may be focused upon issues related to food, eating and body size, shape and image. The psychological components of this disorder intertwine with and support the behavioral aspect of this disorder. In a study reported by the NIH, 34% of bulimic patients reported having injured themselves at sometime in their lives, and 21.3% reported having injured themselves in the last 5 months.

Best Practices Diagnostic Approaches: An accurate diagnosis of this disorder will generally require gathering a thorough history of the client, including a detailed history of eating and nutritional habits, perceptions and values about food, eating, and body image, and a history of purging and dieting strategies used. A history of self-injurious behaviors should also be gathered, due to the high incidence of cutting and other self-harming actions among persons with BN. Because there may be hereditary factors involved in this disorder, it is also recommended that a family history of problems with eating disorders and/or obsessive and compulsive disorders be taken. There is also a very high level of comorbidity with substance abuse, so a detailed history of substance abuse should be gathered. Additional history to be taken includes developmental milestones and when they were reached, history of the birth mother prenatally and during the pregnancy, a history of nutritional deficiencies, any illnesses, injuries or exposures to toxic substances that may have been experienced by the mother during pregnancy or the child at any time, and a family history of mental health conditions that may have contributed to the disorder. There are also assessment tools that may be utilized, including a self-report questionnaire, such as the SCOFF questionnaire, or something slightly more formal, such as the Eating Disorders Examination-Questionnaire (EDEQ). The Bulimic Investigatory Test, Edinburgh (BITE) questionnaire is a brief test for the detection and description of bulimia nervosa. Because there are numerous medical conditions that may be created from bingeing and purging behaviors, a full medical examination is recommended. This assessment would be conducted by a health professional with specialization in addressing eating disorders, and would include a thorough medical assessment, including test to determine problems with blood sugar, metabolite imbalance, and other medical assays that would determine level of severity and safety risks. Because self-induced vomiting can erode tooth enamel, it is also recommended that a history of regular dental care be gathered. Given the high overlap between Borderline Personality Disorder and BN, a thorough assessment process should gather information about any risk of suicidal intentions.

Best Practices Treatment Approaches: Treatment approaches for Bulimia Nervosa will typically begin with Cognitive Behavioral Therapy, combined with medication therapy utilizing fluoxetine, a combination which research has shown to be more effective than either treatment alone, according to the NIH. This may be supplemented by the use of a Relapse Prevention Plan, a tool that has been used successfully with addictive disorders. The goal of the relapse prevention plan is to identify triggers for relapse into problematic behaviors and develop a plan to prevent the triggers from turning into active pathologies. Treatment may also consist of addressing some of the underlying risk factors that contribute to the development of BN: low self-esteem, difficulty expressing negative emotions, perfectionism, and societal pressures to reach certain standards of beauty. Patients with bulimia nervosa may have concurrent medical conditions, including electrolyte and acid-base abnormalities, and these must be treated medically. Bulimia nervosa is also often associated with depression, borderline personality disorder, substance abuse, self-injury, and a troubled family life, and effective treatment will address these other complications, as appropriate.

Other Conditions to Rule Out: This disorder must be distinguished from Anorexia Nervosa, purging type, the key differentiating feature being the extreme fear of weight gain predominating in Anorexia, and a fear of loss of control over eating predominating in Bulimia. Patients with Bulimia are more likely to maintain a body weight that is within or somewhat above normal parameters for height and age. This disorder must also be distinguished from Binge Eating Disorder where binge eating is interspersed with efforts to control eating and reduce weight through primarily food restrictive behaviors. Bulimia Nervosa tends to present with more rapid and immediate attempts reverse the effects of a binge by purging or fasting behaviors. There is considerable overlap between these two diagnoses and clients will sometimes transition from one diagnosis to the other in response to internal and external changes. This disorder must also be differentiated from Body Dysmorphic Disorder, the key differentiating feature being that patients with this condition may focus on numerous perceived flaws in their physical appearance, not just their weight and body size. This disorder must also be differentiated from Histrionic Personality Disorder, where dieting and purging may be utilized to maintain the capacity to gain the attention, approval and affirmation of others through the most presentable physical appearance possible. It must be noted that BN may be comorbid with Histronic Personality Disorder, as well as Borderline Personality Disorder, as clients with these conditions have powerful needs to secure the approval of others and may engage in extreme behaviors to maintain their optimal appearance. This condition must also be differentiated from anxiety and trauma related disorders where bingeing may be used to relieve symptoms of anxiety and provide nurturance, followed by periods where the anxiety makes it difficult to eat due to reductions in hunger due to the physiological consequences of elevated sympathetic nervous system activity. Variations in appetite may also accompany depressive and mood disorders, so these must be ruled out as well. There are also a number of medical conditions that may cause alterations to a person’s appetite and weight profile, including thyroid disorders, head injuries or illnesses affecting the hypothalamus, and any number of conditions that interact with hunger, eating and digestion, including diabetes. It is also important to rule out use of substances that may cause fluctuations in normal appetite.

Comments: This disorder should generally not be diagnosed by Master’s level mental health clinicians who do not have specialized skills in diagnosing and treating eating disorders. Furthermore, due to the numerous medical conditions that may accompany BN, it is always recommended that the treatment of this disorder be handled in coordination with other medical professionals who have familiarity with this condition. Self-injury is a common occurrence in patients with BN, so assessment for self-injury should always be conducted more conscientiously in clients with this disorder, with the expectation that clients may be reluctant to provide consistently truthful information about this aspect of their condition. Early diagnosis and treatment of this disorder, before it becomes more entrenched, is associated with significantly improved treatment outcomes.



Avoidant/Restrictive Food Intake Disorder Summary Page

DSM-5 Code:       F50.8 Avoidant/Restrictive Food Intake Disorder


Common Specifiers:
• In remission

Etiology of Avoidant/Restrictive Food Intake Disorder: This disorder is one that tends to arise at an earlier time in the developmental process, typically in infancy or childhood, although symptoms may present or persist into adulthood. Unlike Anorexia Nervosa or Bulimia Nervosa, the driving forces behind the aversion to eating is not connected to fear of gaining weight, but may be driven instead by low appetite or a lack of interest in food or eating, uncomfortable physiological responses to eating and digesting food, and/or negative reactions to the sensory characteristics of food (texture, consistency, color, odor, etc), On a different track, this disorder may also be caused by fears and worries about aversive consequences of eating, such as choking on the food or vomiting the food, particularly if there has been a trauma producing incident where a conditioned response is created. This disorder frequently accompanies developmental disabilities, autism spectrum disorders, and/or Obsessive-Compulsive Disorder, or may be seen in children whose presentation does not meet full guidelines for these disorders, but who present with signs and symptoms or traits of these disorders. For this disorder to occur, there may be developmental disruptions to brain development in certain key areas of the brain associated with appetite and eating, and/or there may be some neurological trauma due to injury or illness that may contribute to this disorder. This disorder may also accompany various presentations of problems with sensory integration and/or may have connections to neurological functioning in areas of the brain that are associated with OCD, including the orbitalfrontal cortex, anterior cingulated cortex, and the caudate nucleus.

Prevalence: There is no reliable information on this disorder as of this time, however the prevalence may be as high as 5% in children, with this disorder appearing more frequently in boys that in girls. Many children outgrow this disorder as their mature, so prevalence rates likely decline throughout the aging cycle.

Clinical Manifestations: Primary manifestations of ARFID include avoidance of food and eating leading to clinically significant weight loss or failure to achieve age appropriate weight gain or overall growth, with possible nutritional deficiencies as a result of food avoidance. The malnutrition may lead to secondary symptoms of lassitude, low energy, and/or physiological problems associated with missing or inadequate vitamins and other nutrients.

Best Practices Diagnostic Approaches: An accurate diagnosis of this disorder will generally require gathering a thorough history of the client, including a detailed history of eating and nutritional habits, developmental milestones and when they were reached, history of the birth mother prenatally and during the pregnancy, a history of nutritional deficiencies, any illnesses, injuries or exposures to toxic substances that may have been experienced by the mother during pregnancy or the child at any time, and any food intake or regurgitation history that may have been traumatic in ways that contributed to the disorder. Because of the high level of comorbidity with other mental health issues, a variety of neurodevelopmental disorders must be assessed and ruled out. Additionally, referral to medical providers who specialize in this disorder and can provide a full diagnostic assessment of the patient should always be undertaken, as there are numerous medical conditions, such as Celiac Disease or other autoimmune disorders, that may produce signs and symptoms similar to this diagnosis. There may also be previously undiagnosed physiological problems with swallowing that may be responsible for the aversion to eating, so referral for assessment of this problem must be considered. Coordination of care with the client’s primary care physician should be implemented, so that the diagnostic information can be forwarded to a central care management party.

Best Practices Treatment Approaches: Treatment approaches for ARFID will be dependent upon the etiological factors that are responsible for the disorder. For patients whose causative factors include some sort of traumatic incident related to food intake, digestion or regurgitation, an approach that incorporates some combination of Cognitive Behavioral Therapy and systematic desensitization would be indicated. For patients whose causative factors are concerned with sensory disturbances, referral to an occupational therapist who specializes in sensory integration therapy might be indicated. For patients whose causative factors are related to problems with swallowing, referral to an ENT specialist and/or physical and occupational therapist may be indicated. Coordination of care with the client’s primary care physician should be implemented, so that the overall treatment plan can organized and coordinated by a person in charge of overall care.

Other Conditions to Rule Out: This disorder must be distinguished from Anorexia Nervosa and Bulimia Nervosa, the key differentiating feature being the absence of worry about body shape and size in patients with ARFID, as opposed to patients with AN and BN. This condition must also be differentiated from anxiety and trauma related disorders where food avoidance is driven by other psychological considerations. Variations in appetite may also accompany depressive and mood disorders, so these must be ruled out as well. There are also a number of medical conditions that may cause alterations to a person’s appetite and weight profile, including thyroid disorders, head injuries or illnesses affecting the hypothalamus, and any number of conditions that interact with hunger, eating and digestion, including food allergies and intolerances. It is also important to rule out use of substances that may cause reductions in normal appetite in ways that may cause the patient to lose weight or not gain weight, including stimulant medications to treat ADHD.

Comments: This disorder should generally not be diagnosed by Master’s level mental health clinicians, but should be referred for further assessment to a treatment team able to perform the kinds of medical tests necessary to rule out the numerous other conditions that may present with similar signs and symptoms. For children with this disorder, the pediatrician is the proper party to task with diagnostic responsibilities and with coordination of treatment planning. If psychiatric care is needed, or if psychological testing is determined to be required, the PCP should be encouraged to take charge of making those other referrals. Because this disorder can create life and health threatening nutritional deficiencies, appropriate diagnosis and treatment should begin as quickly as possible.



Pica Summary Page

DSM-5 Code:        F98.3 Pica (children)
                              F50.8 Pica (adults)

Common Specifiers:
• In remission


Etiology of Pica: The etiology of this disorder is largely not known or understood. In the majority of instances, the ingestion of non-nutritive substances is driven by some nutrient deficiency, such as low iron or vitamins that are missing from the diet, particularly during pregnancy. It is also seen in association with other disorders that create cognitive deficits and problems with decision making, such as intellectual disability, autism spectrum disorder or schizophrenic spectrum disorders. It is also associated with skin picking disorder and trichotillomania, as well as OCD.

Prevalence: There is no reliable information on the total prevalence this disorder as of this time, however according to the NIH, a pica may be detected in up to 50% of persons with iron deficiency.

Clinical Manifestations: Pica consists of the compulsive eating of non-nutritive items. For a diagnosis of pica to be applied, the eating must not be practiced within a culture in which a non-nutritive substance ingestion, like clay in the rural South, is considered a normal practice.

Best Practices Diagnostic Approaches: An accurate diagnosis of this disorder will generally require gathering a thorough history of the client, including a detailed history of eating and nutritional habits, developmental milestones and when they were reached, history of the birth mother prenatally and during the pregnancy, a history of nutritional deficiencies, any illnesses, injuries or exposures to toxic substances that may have been experienced by the mother during pregnancy or the child at any time. Because of the high level of comorbidity with other mental health issues, a variety of mental health disorders must be assessed and ruled out. There may be serious consequences of swallowing certain non-nutritive items, so a referral to a physician must always be made for examination of medical problems related to the pica.

Best Practices Treatment Approaches: Treatment approaches for Pica will be dependent upon the etiological factors that are responsible for the disorder. For patients whose causative factors include iron deficiency – the majority of cases in which Pica occurs – iron supplements will be recommended and will likely extinguish the behaviors quite quickly. For patients whose pica is associated with some kind of neurodevelopment disorder, obsessive-compulsive disorder, or schizophrenic disorder, treatment will consist of establishing a routine of supervision, limit setting, and reinforcement scheduling to prevent further ingestion and extinguish the behavior. For patients whose Pica is comorbid with intellectual disabilities, there may also be medications that can help reduce the eating disorder.

Other Conditions to Rule Out: This disorder must be distinguished from Anorexia Nervosa and Bulimia Nervosa, the key differentiating feature being the absence of worry about body shape and size in patients with ARFID, as opposed to patients with AN and BN. This condition must also be differentiated from anxiety and trauma related disorders where food avoidance is driven by other psychological considerations. Variations in appetite may also accompany depressive and mood disorders, so these must be ruled out as well. There are also a number of medical conditions that may cause alterations to a person’s appetite and weight profile, including thyroid disorders, head injuries or illnesses affecting the hypothalamus, and any number of conditions that interact with hunger, eating and digestion, including food allergies and intolerances. It is also important to rule out use of substances that may cause reductions in normal appetite in ways that may cause the patient to lose weight or not gain weight, including stimulant medications to treat ADHD.

Comments: This disorder should generally not be diagnosed by Master’s level mental health clinicians, but should be referred for further assessment to a treatment team able to perform the kinds of medical tests necessary to rule out the numerous other conditions that may present with similar signs and symptoms. For children with this disorder, the pediatrician is the proper party to task with diagnostic responsibilities and with coordination of treatment planning. If psychiatric care is needed, or if psychological testing is determined to be required, the PCP should be encouraged to take charge of making those other referrals. Because this disorder can create life and health threatening nutritional deficiencies, appropriate diagnosis and treatment should begin as quickly as possible.



Rumination Disorder Summary Page

DSM-5 Codes:      F98.21 Rumination Disorder


Common Specifiers:
• In remission

Etiology of Rumination Disorder: The etiology of this disorder is largely not known or understood. It is most commonly seen in association with intellectual disability. In infants, it is thought to be caused by a lack of nurturing or physical contact and, a subsequent attempt to use the food as a soothing mechanism. There may also be as yet undefined biological factors that contribute to rumination disorder.

Prevalence: There is no reliable information on the total prevalence this disorder as of this time.

Clinical Manifestations: Rumination Disorder consists of the regurgitating and reconsuming of food that has already been swallowed. This may be difficult to discern, as ruminating behaviors might not be noticed except for expansion of the cheeks when food re-enters the mouth, and a bad odor on the client’s breath.

Best Practices Diagnostic Approaches: An accurate diagnosis of this disorder will generally require gathering a thorough history of the client and his/her history of rumination. Because this disorder is most commonly seen in clients with development disabilities, this assessment process should also include a detailed history of developmental milestones and when they were reached, history of the birth mother prenatally and during the pregnancy, a history of nutritional deficiencies, any illnesses, injuries or exposures to toxic substances that may have been experienced by the mother during pregnancy or the child at any time. There may be medical complications of this disorder, including dehydration that can become dangerous, so a referral to a physician should routinely be made if there is evidence of this disorder.

Best Practices Treatment Approaches: Treatment for rumination disorder depends on the cause of the behavior. The treatment of adult patients with this disorder may include giving them chewing gum to use when rumination might normally occur. Behavior modification techniques that help a patient to unlearn the ruminating behavior have also been used. Infants who are thought to ruminate pursuant to attachment disruptions and affection deficits may improve if improvements in the parent-child relationship are made, especially with regard to feeding behaviors. Approaches to create these improvements may involve therapy and parenting education to create a stronger bond between the parents and the child. Referral for supervision by a physician should routinely be made.

Other Conditions to Rule Out: This disorder must be distinguished from Bulimia Nervosa in adults, the key differentiating feature being the re-consumption of the food pursuant to regurgitation. There are also a number of medical conditions that may cause involuntary regurgitation to occur, so referral for medical services to rule out this possibility should always be considered.

Comments: This disorder should generally not be diagnosed by Master’s level mental health clinicians, but should be referred for further assessment to a treatment team able to perform the kinds of medical tests necessary to rule out the other conditions that may present with similar signs and symptoms. For children with this disorder, the pediatrician is the proper party to task with diagnostic responsibilities and with coordination of treatment planning. Because this disorder can create life and health threatening nutritional deficiencies, appropriate diagnosis and treatment should begin as quickly as possible.

 

Eating Disorders Factoid

At any given time, 10% of adolescent and adult women report symptoms of an eating disorder

Source: The Academy for Eating Disorders

 

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