Script Definition Anorexia can be defined as the refusal to maintain a bodyweight equal to or above a normal weight for the

the individuals age and height There is an overwhelming fear of putting on bodyweight and becoming obese Anorexics have a distorted view of the shape and size of their body and they often deny that they are suffering from the illness Their weight loss is self-induced through several ways including o Fasting o The misuse of laxatives or diuretics o Self-induced vomiting o And/or excessive exercise

Next Slide There are also 2 subtypes of anorexia nervosa o The first is the restricting type in which the anorexic does not engage in the regular binge/purging cycle They refuse to eat and deny their hunger o The 2nd type is called binge-eating/purging type. This is characterized by a regular cycle of binging followed by purging due to feelings of lack of control In other words, they would eat excessively in a short period of time, and then purge through self-induced vomiting or using laxatives or diuretics Anorexics could also be characterized as anxious and reserved individuals They have a negative/low self esteem about their bodies but are perfectionists that thrive off the sense of having control over some aspect of their life They achieve this by focusing their attention on an easily controllable aspect, which is their body

Diagnosis According to the DSM 4, the diagnostic criteria for anorexia is o the refusal to maintain a bodyweight at or above a minimally normal weight for age and height o this weight loss leads to a weight 85% of that expected o an intense fear of gaining weight or becoming fat, even though underweight o a disturbance in the way ones bodyweight or shape is perceived or denial of illness o and an absence of at least 3 menstrual cycles which is called amenorrhea

Screening Tools : Some examples of the different assessment methods include: o o Structured interviews and screening tools are different methods to help diagnose anorexia and they produce a reliable and valid assessment for eating disorders Some screening tools used include The Eating Disorders Examination (EDE) This is the most reliable method for evaluation as it reveals behavioral features and associated conditions of anorexia Comorbidites Obsessive-Compulsive Features- Checking rituals, washing, slow, doubting Major Depression- about 20% of anorectics Personality Disorders- avoidant (30%), dependent (10%) o Over dependency All social activity may evolve around one friend or family member- frequently the spouse or partner Substance Abuse and Stress o Other substances are used, most common is cigarettes (47%) to suppress appetite in anorectics Anxiety Disorders o Interpersonal sensitivity Social anxiety about appearance and eating habits More common in bulimics Unipolar and Bipolar Disorders The Eating Attitudes Test (EAT) is another clinical assessment for anorexia The Eating Disorders Inventory (EDI) measures cognitive and behavioral factors such as their drive for thinness and body dissatisfaction This includes a 64-item self- administered questionnaire A SCOFF test could also be done If 2 or more affirmative answers given, indicate an eating disorder Some questions include: Do you worry you have lost Control over how much you eat? And Do you think you are too Fat, even though others say you are thin?

Symptoms symptoms of anorexia include

dizziness/weakness, fainting spells, constipation, poor concentration and an increased sensitivity to cold

Physical Signs include loss of subcutaneous tissue which is immediately beneath the skin containing fat cells, o muscle wasting and weakening, loss of bone mass o Aecro-sian-osis: which is characterized by the blueness and coldness in the fingers and toes o lah-noo-go: which are soft hairs that develop on the chest, back and arms o peripheral neu-rop-othy: which is damage to the peripheral nervous system leading to a loss of sensations o dry, rough, discolored skin o and scaphoid abdomen in which the stomach becomes concave it is best to diagnose anorexia through clinical interviews but it is also essential for patients to be tested to ensure that the weight loss is not due to medical causes such as peptic ulcers or esophageal (jee-ul) disease

Etiology (eetiology) In terms of etiology, anorexia is viewed according to the multidimensional risk perspective which explains that there are many factors which overlap one another to cause this illness To name a few, there are biological causes pertaining to genetics and environmental factors which include the family and society. Certain life events or psychodynamic factors could also lead to the development of anorexia

Next Slide Family studies indicate that 1st degree relatives of anorexic patients are 6x more likely to develop an eating disorder as well Twin studies suggest that if 1 identical twin has an eating disorder, there is an approximate 70% chance that the other twin will also develop an eating disorder In fraternal twins, however, there is only a 20% of the other twin developing an eating disorder Also, studies conducted involving families with at least 2 members with an eating disorder showed linkage regions on chromosomes 1, 3 and 4 Another biological factor pertains to low or high serotonin levels. This neurotransmitter is involved in regulating our hunger, mood and impulse control For the binge/purge type of anorexia, low levels of serotonin are said to be increased during periods of excessive eating and the person feels better, causing the body to binge on high-carb foods

Conversely, if serotonin levels are high, this could create feelings of anxiety. By restricting ones diet, feels of calm and control will be regained The act of binging could also lead to an imbalance in serotonin levels, contributing to an already existing problem The hypothalamus is also key in explain eating disorders. The 2 parts, ventromedial hypothalamus and lateral hypothalamus help control hunger These parts, along with chemicals in the brain comprise the weight set point which is the weight an individual is predisposed to maintain When the weight falls below this set point, the lateral hypothalamus, which produced hunger, is activated, producing a desire to binge o

Family Environment The family has a huge impact on the development of eating disorders and the relationships developed between food and body image Middle- Upper class, successful o Households in which a lot of emphasis is given to thinness, physical appearances and dieting contribute to anorexia as well as any criticisms regarding weight and body shape from family members Concerned about physical appearance o Literally and figuratively Physical appearance (body image), and also how they appear to the outside world, portray to friends co-workers etc. Rigid, strict o There is also very poor communication between family members Little expression o Unable to express conflict or negative feelings o Next to no emotional expression/ contact (hugs, kissing etc) Can be over dependent and invasive, controlling, enmeshed family pattern o Edge into life, and personal business o Enmeshed family pattern is a good term to describe these household as the family is often overbearing and very involved in each others business o Behaviors associated with anorexia such as self-starvation can then serve to regain a sense of control Girl who was 7 parents and older sister (11) was having contest for who could lose the most weight, sister was ridiculed for gaining weight (even though going through puberty)

Life Events Parental neglect or abuse could also lead to the development of eating disorders

 Society

Separation from loved ones or death is also a huge factor

The Western society is very influential as well The Western standard of beauty is being thin and a lot of emphasis is given towards being skinny It symbolizes attractiveness, success, happiness and intelligence according to the media In an attempt to meet these social expectations and standards of female attractiveness one may begin to diet especially when comparing themselves to what they see in magazines or in ads A lot of pressure is put on young teens who are already at a vulnerable stage to meet these standards of beauty and attractiveness

Cultural Aspects More common in Western Culture o thin-body is ideal and demanded since early 20th century o In the 1960s dieting and thinness became a cultural obsession Young, Middle-Upper class Caucasian females Immigrants develop abnormal eating habits o Immigrants take a few years, but once they adjust to the dominant culture, and media Rare in developing countries o Increases as the country develops economically Traditional Kenyan women prefer larger female figures o Kenyan women immigrated to England, and once familiar with the media and dominant culture ways, still preferred a larger female figure

Next Slide Lastly, eating disorders could be caused by ego deficiencies This could be a reflection of ineffective parenting in which the parents fail to appropriately attend to the childs needs These children grow up unaware of their own feelings and emotions As a result, anorexics could be described as alexithymic ah-lex-eh-thigh-mic, meaning they are unable to label their emotions so they rely on others opinions and seek their approval. They also feel no sense of control so to overcome this helplessness, they control their body shape and weight

Anorexia in Men Anorexia in males remain constant while female anorectics increase Conflicts with sexual identity Often found in the gay community over the heterosexual population o Particularly those who play the female role in the relationship Low sexual interest/ drive

 Elderly

During puberty men gain more muscle then fat, unlike women

Malnutrition is common Area of control in their life o Symptoms are non-specific, family members are usually the ones that notice relative has stopped eating, and advise Their lives are most likely controlled- family members, nursing homes, PSW workers etc.

May be a comorbidity to other disorders o Dementia Loss of taste, appetite, will eat normally with others but stop eating when left alone Depression o Associated with decrease in appetite and weight loss

Paranoid Disorder Belief that food is being poisoned

Character Disorder Personality may become heightened in old age, so if demanding or dependent, behavior may be hard to change

Psychodynamic Model According to Freud, behaviors associated with anorexia are a result of unconscious impulses which threaten to break into the conscious mind These sources come from the id which are our instinctive behaviors When these id impulses are recognized by the ego, our self-awareness, a person is driven to fulfill these impulses However, the superego, works to oppose the id impulses As a result, the ego resorts to defense mechanisms One of the most potent defense mechanisms are repression in which impulses are forced back into the unconscious

In turn, this weakened ego creates neurotic anxiety In an anorexics case, the anxiety is related to sexual impulses related to past events including the onset of puberty or fear of sexual maturity Their reaction to food could be an unconscious strategy used to maintain control over their family and deny their sexuality

Social Cognitive Model 3 factors are stressed to explain this model 1st is the overt behavior of an individual 2nd, the persons beliefs, thoughts and emotions And lastly, the environment or social interactions with others

Next Slide These factors could be viewed in a diagram as such Personal factors include expectations, beliefs and attitudes of the person These beliefs and attitudes are reflections of past experiences For instance, one may believe that they are overweight This in turn, influences their behavior to diet and regulate their food consumption As weight is lost due to dieting, environmental factors such as peers, could confirm the belief that being thin is good. Positive remarks then increase the tendency to diet. This perspective also emphasizes the importance of observational learning Anorexic behaviors could be imitations of symbolic aspects such as social values or standards These values and social standards are often illustrated in magazines, books and on TV They all suggest, through models and actresses, that being thin is attractive and beautiful It is also more common that anorexia be prevalent in household in which the parents often diet In sum, this model believes that in order to understand the behavior of people, it is necessary to know how and what they think

Behavioral Model Behaviorists believe that subjective assumptions should not be made regarding a person such as their thoughts and emotions as described in the social-cognitive model Rather, they believe that thoughts and feelings are produced by experience and directly related to what the person does So they eliminate the relationship between the environment and behavioral responses Instead of focusing on what the anorexics may say about themselves, behaviorist focus their attention to events that follow their behaviors This model is based on operant conditioning in which a persons behaviors could either strengthen or weaken according to their consequences In the case with anorexia, positive reinforcement involves social consequences Their behavior is followed by approval and attention which would increase their need to diet The behaviors of refusing to eat is maintained by how others react to that behavior So this model doesnt really focus on what caused self-starvation rather focus to change the conditions which maintain the problem

Case Study Picture Case Study of Karen Carpenter Teens: 17, brother called her Fatso but she only weight 145 lbs Big hips were in the family, genetics Lost 25 pounds, around 120 at 17-23 years old 20, began to sing lead, become more self conscious as she wasnt hidden behind drums Grew up in family including her parents, an older cousin and brother Was a singer teased for being overweight as a child Often behaved energetic, motivated and sincere When 13, family moved to California She was popular, well liked, friendly, outgoing, unlike her brother who was older, and she protected him Idolized him worked with her brother in late teens and early 20s

The Family Mother showed preference of son Dad passive, conflict-avoidant Mother was dominant- high anxiety Mother controlling

 Picture

Put down by mother in comparison to her brother Felt unattractive, inferior to her brother, overweight No physical affection John took after mother as being very controlling At home, controlled by mother, at work, controlled by brother

The Celebrity 23, exposed to media, criticized body image on TV Brother was in agreement; media was critical of her weight began dieting at 23 24 family noticed she wasnt eating-rib cage showed through clothes; didnt see anything wrong She was in denial Would exercise excessively 26 took 2 months of bed rest to recover from exhaustion Continuously sick, immune system low Addicted to laxatives, took 10 times as many thyroid pills as prescribed

Final Years Picture Complications There are serious complications that could arise from anorexia therefore it is crucial to recognize and diagnose the illness as soon as possible Anorexics suffer from severe malnutrition and dehydration due to self-starvation Gastrointestinal complications are also common in anorexia although are more prevalent in bulimia Some more prominent complications resulting from anorexia include amenorrhea which is the absence of at least 3 or more menstrual cycles Married at 30, knew him for a few months Marriage fell apart; husband was controlling Hospitalized in New York after seeing may therapists what kind of therapy did she receive? Never felt cared for, family didnt support her, but she improved in the hospital (went from 83 pounds to 108), overcame her addiction to laxatives Insisted on leaving after 6 months of treatment Upon her return home, ipecac-induced vomiting, increased to entire bottle Died of a heart failure which could have been facilitated by ipecac found in her system

Prolonged amenorrhea can lead to osteopenia which is classified by a low bone density between -1 and -2.5 standard deviations from the mean Low bone density weakens the bones and could cause fractures Osteoporosis is a more serious form than osteopenia as it is characterized by a bone mineral density below -2.5 standard deviations from the mean Anorexia in adolescents is especially dangerous as they would experience a loss in skeletal growth which cannot be retrieved

Treatment The ultimate purpose of treatment for anorexia is to restore the patients psychological and physical health It is also important to help patients reestablish and maintain healthy eating patterns The treatment also includes a chance for the patient to correct their disturbed self-perceptions about their body and to develop a positive attitude towards food Prevention of relapse is also key which can be achieved through overcoming underlying psychological problems All these goals can be achieved through individual therapy

People The treatment is administered by a multidisciplinary team consisting of a primary care physician, a psychiatrist or psychotherapist and a dietitian. The physician monitors the patients physiological status such as shifts in weight and blood pressure and treats the symptoms and complications of anorexia The psychiatrist or psychotherapist also assess behaviors and symptoms and provides individual, family or group therapy The dietitian ensures that the patient receives adequate nutrients and helps the patient establish structured eating patterns by educating them regarding health and eating

Treatment Methods The different types of treatment methods are o In-patient treatment in which the patient is hospitalized o Out-patient treatment o Psychological approaches o Psychotherapy o And pharmacology (pharma-cology) which is used as a last resort

Next Slide A patient requires hospitalization if their condition is severe This includes a loss of body weight 30% or less than the original body weight Hypotension

Hypothermia, with a body temperature less than 35.6C Severe food refusal Failure of out-patient therapy Or if comorbid conditions interfere with the treatment During this stage, the goal is to achieve 90% of patients original weight Once the weight has been restored, and the mental and emotional status of the patient has improved, they could begin other forms of therapy

Out-patient This treatment is ideal as the patient is receiving treatment in a realistic setting During this stage, the patient receives various forms of therapies

Next Slide Psychodynamic therapy Focuses to increases ones self-awareness and helps the patient better understand the factors which manifested their disorder

Psychotherapy Includes individual therapy, family and group therapy Family therapy aims to develop a positive and healthy foundation between family members. Sometimes, it is important for a patient to separate themselves from their family as the family has a lot to contribute to the disorder

Group therapy Provides encouragement in a comfortable environment and is the perfect opportunity for patients to vent out frustrations to those who will understand them

Cognitive Behavioral Therapy The behavioral aspect deals with having the patient track their own behaviors, attitudes, eating and weight in order to help them realize their false beliefs about their body In the cognitive component of this therapy, their thoughts are restructured by educating them about healthy eating and helping them understand their thoughts and why they may feel a certain way

Pharmacological Therapy It is recommended to wait until weight is restored before administering drug treatments because side-effects of medication may complicate effects of malnutrition and re-feeding process

Because drug therapy cannot determine the underlying causes of anorexia, they are not very effective unless the situation is severe Antipsychotic drugs could be used to get rid of obsessions regarding weight and body shape as they resemble delusions Olanzapine (oh-lan-za-peen) and resperidun (rus-per-eh-dun) o Also have positive effects on weight gain and induce improvement of anxiety and obsessive thoughts Antidepressants target symptoms of depression and OCD Serotonin and (nor-epin-ef-rin) reuptake inhibitors are ideal as they target anxiety and mood swings that may persist after weight gain

*Karen Carpenter received therapy in New York and then changed places and received intravenous
feeding