Eating Disorders 101: A Basic Guide for Chemical Dependency Professionals

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Eating Disorders 101 A Basic Guide for Chemical
Dependency Professionals

• Michelle L. Staub,
• LPC, CAC Diplomate
• Caron Treatment Centers
• Wernsersville, PA, USA

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Goals

• Understand diagnostic criteria of eating
  disorders
• Understand the relationship to mood disorders
• Understand the correlation between ED and CD
• Theoretical Causes of Eating Disorders
• Understand components of an evaluation

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Goals Continued

• Understand the components of effective treatment
• Understand the impact of culture on eating
  disorders
• Understand the impact of ED on males
• Sample treatment plans

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Definition

• Eating disorder is defined as a persistent
  disturbance of eating or eating related behavior
  that results in the altered consumption or
  absorption of food and that significantly impairs
  physical health or psychological functioning.
• Brownell Fairburn

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Anorexia Nervosa

• Refusal to maintain body weight at 85
• Intense fear of gaining weight
• Disturbance in the way ones body weight is
  experienced
• Amenorrhea
• Subtypes Restricting or Binge-eating/purging
  based on current episode

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Anorexia Nervosa

• Highest mortality rate of all DSM diagnosis 10
• Starvation causes the brains ventricles to
  increase in size and the cortical mass decreases
• Gray and white matter of the brain does not
  completely return to normal even after 12 months
  of weight restoration

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Anorexia Nervosa

• .5 1 of the general population
• 10-20 times more common in females than males
• 12 - 21 of anorexic women also abuse chemicals
• Dr. Susan Gordon

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Bulimia Nervosa

• Self evaluation is unduly influenced by body
  shape and weight
• Does not occur exclusively during episodes of
  Anorexia
• Subtypes include purging type self induced
  vomiting, laxative, diuretics and enemas.
• non-purging type fasting or exercise

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Bulimia Nervosa

• Eating more food than most people in a similar
  time frame
• Lack of control over eating
• Recurrent inappropriate compensatory behavior to
  prevent weight gain can include self-induced
  vomiting, diuretics, laxatives, enema,
  medication, fasting, excessive exercise
• Occurs minimally twice a week for three months

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Bulimia Nervosa

• 1 3 of women in the general population
• Twice as common in females than males
• 9 - 55 of bulimic women also abuse chemicals
• Dr. Susan Gordon

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Binge Eating Disorder

• Currently under review for separate diagnosis
• Eating a large amount of food in a discrete
  period of time
• A sense of lack of control over eating
• Three or more of the following
• Eating much more rapidly than normal
• Eating until uncomfortably full
• Eating large amounts of food when not physically
  hungry
• Eating alone due to embarrassment
• Feeling disgusted, depressed or guilty after
  overeating

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Binge Eating Disorder (cont.)

• Occurs minimally twice a week for six months
• Not associated with the regular use of
  inappropriate compensatory behaviors
• Often, but not always, overweight or obese
• 2 of the general population
• Slightly more common in females than males

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Eating Disorder, NOS

• Meets most of the criteria for Anorexia or
  Bulimia with the exception of one criteria
• Regular use of inappropriate behaviors after
  ingesting small amounts of food
• Repeatedly chewing food without swallowing

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Disordered Eating

• Currently, there is not a lot of published
  information
• Numerous studies are currently being conducted.
• Theory is an individual may have disordered
  eating which impacts quality of life but not
  diagnosed with an eating disorder.
• Atkins Diet, South Beach, etc.
• Yo-Yo dieting

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Relationship to Mood Disorders

• Depressive Disorders
• Most prevalent to Bulimia
• 50 of individuals with eating disorders are also
  diagnosed with Major Depressive Disorder
• Typically, major depression is a consequence of
  the eating disorder
• Depressive symptoms of ED patients are different
  from other patients with major depressive
  disorder
• As the eating disorder improves so does the
  depressive symptoms

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Relationship to Mood Disorders (cont.)

• Anxiety Disorders
• Social phobia is common among eating disorder
  patients
• Obsessive Compulsive Disorder also has a high
  prevalence among eating disorder patients --
  Theory OCD symptoms are a consequence of the
  dieting and resulting starvation.
• Brownell Fairburn

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Diagnostic Complications between ED and CD

• Which is primary?
• Is chemical use part of the eating disorder or a
  separate diagnosis? Or vice versa?
• Typical drugs of choice heroin, cocaine,
  alcohol, tobacco, caffeine and stimulants

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Common Characteristics between ED and CD

• Patients are in denial
• Hide behaviors
• Chronic and fatal
• High rates of relapse
• Effects physical, psychological, social , family
  and overall interactions
• Eating Disorders are not about food, CD is not
  about the alcohol

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Common Characteristics between ED and CD (cont)

• Easier to think about calories/drinking or using
  than to deal with painful feelings and emotions
• Treatment needs to be multi-disciplinary and
  multi-focused

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Common Risk factors between ED and CD

• Tend to emerge in adolescence
• Symptoms tend to increase in times of stress
• Many have a history of physical and/or sexual
  abuse
• Co-occur with other psychological diagnosis
  (depression, anxiety)
• Bulimia is the most common ED diagnosed in CD
  population

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Influences During Active Addiction

• Eating Disorders promote the use of substances
  that enhance eating disorder behaviors
• Some substances (alcohol and marijuana) produce
  weight gain and trigger ED behaviors in an
  attempt to reduce weight
• Substances decrease self-control and trigger ED
  behaviors in an attempt to regain control
• Dr. Susan Gordon

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Influences During Treatment

• Other non-treated co-occurring psychological
  conditions can trigger both CD and ED
• Weight gained in CD treatment can trigger relapse
  to ED behaviors
• The loss of ED and/or CD as a coping skill can
  trigger relapse to another untreated disorder
• Dr. Susan Gordon

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Other Misused/Abused Substances

• Diet Pills
• Fat Burners
• Diuretics
• Ipecac
• Laxatives

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Diet Pills

• Phenylpropylalanine (PPA) no longer available
  due to high incidence of heart attacks and death
• Ephedrine (Ma Huang) 10
• Caffeine 36
• Combination 54
• Remuda Ranch July 30, 2004

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Ephedrine Abuse Complications

• Heart Attack
• Stroke
• Liver failure
• Kidney problems
• Dizziness

• Increased Heart Rate
• Headache
• Nervousness
• Tremors
• Insomnia
• Remuda Ranch July 30, 2004

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Fat Burners

• Most are a combination of ephedra, caffeine and
  aspirin
• Some also contain diuretics and amino acids
• These also include the most recent and popular
  carb blockers

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Diuretic Abuse

• Most common over the counter diuretics contain
• Diuretic/herbal product plus
• Caffeine
• Potassium salts (K)
• Analgesics
• Salicylates
• Acetaminophen
• Remuda Ranch Treatment Centers

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Diuretic Abuse

• Decreased Potassium (K)
• Decreased Chloride (CI-)
• Dehydration
• Magnesium Deficiency (Mg)
• Hyponatremia (Na)
• Hypercalcemia (Ca)
• Remuda Ranch Treatment Centers

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IPECAC

• 28 of bulimic patients had tried at one time
• 3-4 used regularly
• Direct action on the gastric lining
• Some will use to help start vomiting
• Others use as their gag reflex is reduced
• Toxic
• Cardiomyopathy
• EKG changes
• Present as palpitations, skipped heart beats,
  dizziness, chest pains, shortness of breath can
  resemble panic attack.
• Remuda Ranch Treatment Centers

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Theoretical Causes of Eating Disorders

• Family Dynamics and Genetics
• Perfect family places importance on externals
  (appearance) achievements concerned about how
  they are perceived by others.
• Over protective family parents are overly
  involved, children confused about own identity
  and have difficulty with individuation and
  independence
• Chaotic family children are victims of abuse,
  rules are inconsistent, distrusting of themselves
  and others

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Theoretical Causes of Eating Disorders (Cont.)

• Social Dynamics
• Major life transitions puberty, illness, death
  of a loved one
• Societal expectations
• Mother/daughter connection as it relates to
  body image and dieting
• Prejudices against obese people
• Failure at work, school, competitive events
• Traumatic events

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Theoretical Causes of Eating Disorders (Cont.)

• 31 of 8 year olds feel fat
• When girls go through puberty, body fat increases
  165
• 11-14 year old girls normal to gain 40 lbs in
  four years
• Bulimic philosophy shopping, relationships,
  sex, exercise and work

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What can be done in chemical dependency programs
in regards to eating disorders?

• Assess/Evaluate
• Motivate
• Refer

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A Thorough Evaluation Should Include

• Weight history
• Supplement use
• Exercise organized and unorganized
• Dieting history
• Family eating patterns

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Evaluation (Cont.)

• Need to be able to identify
• Symptoms mood
• Severity frequency
• Cognitive impairments
• Biological impairments

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Evaluation (Cont.)

• Assess as part of the medical assessment
  biopsychosocial
• Assessment methods
• Clinical interviews
• Standardized screening tools
• EDI Eating Disorder Inventory
• EAT Eating Attitudes Test
• Advantages economical, brief, easily
  administered
• Disadvantages less accurate than an interview

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Goals of Basic Treatment (Motivation)

• Increase Awareness
• Educate by identifying symptoms and consequences
• Increase motivation
• Identify individual triggers

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Objectives for Treatment (in general)

• Establish/increase motivation for recovery
• Develop a reason to recover
• Develop an identity without the eating disorder
• Legalize food look at food as a source of
  nutrition, not a source of fear

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Objectives for Treatment (Cont.)

• Separate food from feelings by dispelling myths
  about food and weight
• Develop healthy ways to manage feelings assist
  in overcoming thoughts and emotions and focus
  efforts on recovery

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Treatment

• In PHP and inpatient, treatment typically
  addresses the effects and stabilize symptoms, but
  does not typically address the actual eating
  disorder pathology.
• The actual eating disorder pathology is typically
  only addressed in long-term individual
  psychotherapy.

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Treatment Components

• Co-morbidities
• Weight
• Body image
• Readiness for change
• Coping style
• Eating Disorder Center of Denver

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Issues To Address In Therapy

• ED is important to sense of self
• Many refer to the ED as a monster inside the
  individual sees this as a positive influence
• Without the ED, the individual loses identity
  thereby eliminating a perceived effective coping
  strategy

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Treatment Statistics

• 80 who stay in treatment make progress
• 20 drop out and relapse
• Treatment can take 7-10 years or even longer

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Dieting

• Has been normalized within society and is a
  cultural norm
• 35 of normal dieters progress to pathological
• 20-25 develop eating disorders (NEDA, 2005)

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What is the current culture? How does it impact
eating disorders?
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A Childs Culture

• Scraped knee chocolate chip cookie everything
  is ok
• Barbie dolls 57, 100 pounds, size 2 reality
  54, 140 pounds, size 14

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A Teenagers Culture

• A recent study showed a teenager currently has a
  greater fear of being fat, than he/she does over
  cancer, or losing a parent
• 50 of 9 year olds and 80 of 10 year olds are on
  diets

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The Worlds Culture

• McDonalds burger, fries and coke 1950 590
  calories
• 2002 1550 calories
• Jean Kilbourne

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The Worlds Culture (Cont.)

• Portions have dramatically increased
• Since 1990, China has tripled in obesity
• New modern lifestyle everything is already
  chopped and prepared

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University of Minnesota Study

• The effects of mothers dieting had a greater
  influence over sons than daughters
• 2-3 times more likely to worry about weight/body
  image
• 2-3 times more likely to diet
• 7 times more likely to binge

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Media and Eating Disorders

• Ads normalize eating disorders
• Ads depicting a woman are usually 4-5 women to
  create one
• Ads with hands over mouth express themselves in
  other ways not what you say others believe it
  is a symbol not to eat

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Media and Eating Disorders (Cont.)

• Food is replacement for sex good girls say no
  dont eat
• Television reality shows
• Swan
• Extreme Makeover
• Biggest Loser

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Differences Between Males and Females

• Onset for males is a a later age 20.5
• Males focus on waist up
• Males prefer to purge through fasting and
  exercise rather than vomit

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Differences Between Males and Females (Cont.)

• Male messages focus on body shape/image rather
  than weight
• 41 of men are dissatisfied with weight, whereas
  70 are dissatisfied with body image

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Males and Eating Disorders

• Primary drug of choice steroids
• Physical effects of steroid abuse in conjunction
  with compulsive exercise
• Blurred vision, hallucinations, rage, skin
  problems (acne), high blood pressure, joint pain,
  loss of sex drive

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Males and Eating Disorders (cont.)

• Anorexia recent studies show for every four
  females one male is diagnosed
• Bulimia for every eight females one male is
  diagnosed
• Many more men are considered compulsive
  overeaters/binge eating disorder appear equally
  among both genders

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Males and Eating Disorders (cont.)

• These statistics may not be accurate as men do
  not seek treatment
• Only 10 of individuals seeking treatment are
  male
• This is comparable to womens chemical dependency
  treatment 15 years ago

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Male Risk Factors

• Overweight as a child
• Family encouraged dieting as a teenager
• Participates in sports that demands thinness
• Job or profession that demands thinness
• Homosexuality

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Male Characteristics

• Low self-esteem perfectionist
• Avoids conflicts hates everything
• Puts others ahead of themselves

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Sample Treatment Planning
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Goals of Body Image Group

• Provide psychosocial educational information on
  the recovery barriers created by body image
• Provide an opportunity to share with peers
  specific issues related to body image
• Develop a relapse prevention plan that addresses
  both chemical dependency and body image
  concurrently

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Possible Interventions

• I will meet with the staff dietician on a weekly
  basis to discuss my progress on my food plan
• I will cooperate with the medical staff regarding
  lab work
• I will complete an EAT-26 and discuss the results
  with my counselor
• I will initiate conversation at the dining table
  that does not involve food or treatment
• I will participate in weekly blind weights
• I will keep a journal regarding my feeling before
  each meal, my food intake and my feelings
  afterwards

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Possible Interventions (Cont.)

• I will discuss the secondary gains from my
  purging during the weekly group
• I will keep a journal including my thoughts,
  feelings, behaviors, and desires to purge and
  discuss in the weekly group
• I will discuss with my counselor what my purging
  has cost me
• I will identify my triggers and a relapse
  prevention plan and share in the weekly group and
  with my family

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Our Role

• Start where the client is currently
• Create a safe enviornment for change, the place
  of truth
• Provide hope with a vision of recovery
• Do the work together strategize and educate
• Address any resistance

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Conclusion

• Therapists need to be aware of his/her own bias
• Own body image
• Own concerns over weight
• Immediate reaction is to respond to the outside
  rather than focus on the inside
• Food is fuel no more, no less

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References

• Andersen, A. Anorexia Nervosa 11 Areas of
  Advancement. Eating Disorders Review March/April
  2003.
• ANRED. (2002) Treatment and Recovery
  www.anred.com
• Boston College Eating Awareness Team (2002).
  Eating Disorders and Men www.bc.edu
• Brownell, K.D. Fairburn, C.G. (1995). Eating
  Disorders and Obesity A Comprehensive Handbook.
  Guildford Press New York, NY.

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References Cont.

• Diagnostic and Statistical Manual of Mental
  Disorder Fourth Edition. Published by the
  American Psychiatric Association. Washington, DC.
  (1994).
• Gordon, S. (1999). Research Update Eating
  Disorders and Substance Abuse Caron Foundation,
  Wernersville, PA.
• Gordon, S. (2004). Co-Occurring Disorders
  Understanding Addiction with Relationship to
  Eating Disorders Caron Foundation, Wernersville,
  PA.
• Karin Kratina, Nancy King, Dayles Moving Away
  from Diets - 2nd edition, Helm Publishing, Lake
  Dallas, TX (2003).

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References Cont.

• Kilbourne, J. (1999). Cant Buy My Love
  Touchstone New York, NY.
• Remuda Ranch Substance Misused and Abused
  (2004). IAEDP Conference July, 2004.
• Weiner, K.L. and Bishop, E.R. (2004). Levels of
  Care for Eating Disorders IAEDP Conference
  July, 2004.