Chief, Division of Geographic Medicine and Infectious Diseases
Hospital Epidemiologist
Tufts Medical Center
Boston, Massachusetts
Infants with avoidant/restrictive food intake disorder may be irritable and difficult to console during feeding treatment toenail fungus best buy for synthroid, or may appear apathetic and withdrawn medications kosher for passover cheap synthroid 50 mcg on-line. Coexisting parental psychopathology treatment 8 cm ovarian cyst best purchase for synthroid, or child abuse or neglect symptoms during pregnancy buy generic synthroid 25mcg on-line, is suggested if feeding and weight improve in response to changing caregivers medicine 2355 generic synthroid 75 mcg. In infants medications side effects prescription drugs cheap synthroid online visa, children medicine the 1975 buy generic synthroid 200 mcg online, and prepubertal adolescents medications discount synthroid 125 mcg with amex, avoidant/restrictive food intake disorder may be associated with growth delay, and the resulting malnutrition negatively affects development and learning potential. Regardless of the age, family function may be affected, with heightened stress at mealtimes and in other feeding or eating contexts involving friends and relatives. Avoidant/restrictive food intake disorder manifests more commonly in children than in adults, and there may be a long delay between onset and clinical presentation. Triggers for presentation vary considerably and include physical, social, and emotional difficulties. Anxiety disorders, autism spectrum disorder, obsessive-compulsive disorder, and attention-deficit/hyperactivity disorder may increase risk for avoidant or restrictive feeding or eating behavior characteristic of the disorder. Higher rates of feeding disturbances may occur in children of mothers with eating disorders. Food avoidance or restriction related to altered sensory sensitivities can occur in some physiological conditions, most notably pregnancy, but is not usually extreme and does not meet full criteria for the disorder. D ifferentiai Diagnosis Appetite loss preceding restricted intake is a nonspecific symp to m that can accompany a number of mental diagnoses. Underlying medical or comorbid mental conditions may complicate feeding and eating. Feeding difficulties are common in a number of congenital and neurological conditions often related to problems with oral/esophageal/ pharyngeal structure and function, such as hypo to nia of musculature, to ngue protrusion, and unsafe swallowing. Avoidant/restrictive food intake disorder should be diagnosed concurrently only if all criteria are met for both disorders and the feeding disturbance is a primary focus for intervention. Individuals with autism spectrum disorder often present with rigid eating behaviors and heightened sensory sensitivities. However, these features do not always result in the level of impairment that would be required for a diagnosis of avoidant/restrictive food intake disorder. Specific phobia, social anxiety disorder (social phobia), and other anxiety disorders. Specific phobia, other type, specifies "situations that may lead to choking or vomiting" and can represent the primary trigger for the fear, anxiety, or avoidance required for diagnosis. In social anxiety disorder, the individual may present with a fear of being observed by others while eating, which can also occur in avoidant/restrictive food intake disorder. These features are not present in avoidant/restrictive food intake disorder, and the two disorders should not be diagnosed concurrently. Individuals with obsessive-compulsive disorder may present with avoidance or restriction of intake in relation to preoccupations with food or ritualized eating behavior. Avoidant/restrictive food intake disorder should be diagnosed concurrently only if all criteria are met for both disorders and when the aberrant eating is a major aspect of the clinical presentation requiring specific intervention. In major depressive disorder, appetite might be affected to such an extent that individuals present with significantly restricted food intake, usually in relation to overall energy intake and often associated with weight loss. Usually appetite loss and related reduction of intake abate with resolution of mood problems. Avoidant/ restrictive food intake disorder should only be used concurrently if full criteria are met for both disorders and when the eating disturbance requires specific treatment. In order to assume the sick role, some individuals with factitious disorder may intentionally describe diets that are much more restrictive than those they are actually able to consume, as well as complications of such behavior, such as a need for enteral feedings or nutritional supplements, an inability to to lerate a normal range of foods, and/or an inability to participate normally in age-appropriate situations involving food. In factitious disorder imposed on another, the caregiver describes symp to ms consistent with avoidant/restrictive food intake disorder and may induce physical symp to ms such as failure to gain weight. Restriction of energy intal<e relative to requirements, leading to a significantly low body weigfit in tfie context of age, sex, developmental trajec to ry, and physical health. Intense fear of gaining weight or of becoming fat, or persistent behavior that interferes with weight gain, even though at a significantly low weight. This subtype describes presentations in which weight loss is accomplished primarily through dieting, fasting, and/or excessive exercise. Specify if: In partial remission: After full criteria for anorexia nervosa were previously met. In full remission: After full criteria for anorexia nervosa were previously met, none of the criteria have been met for a sustained period of time. Some individuals with this subtype of anorexia nervosa do not binge eat but do regularly purge after the consumption of small amounts of food. Crossover between the subtypes over the course of the disorder is not uncommon; therefore, subtype description should be used to describe current symp to ms rather than longitudinal course. Diagnostic Features There are three essential features of anorexia nervosa: persistent energy intake restriction; intense fear of gaining weight or of becoming fat, or persistent behavior that interferes with weight gain; and a disturbance in self-perceived weight or shape. Individuals with this disorder typically display an intense fear of gaining weight or of becoming fat (Criterion B). Others realize that they are thin but are still concerned that certain body parts, particularly the abdomen, but to cks, and thighs, are " to o fat. Often, the individual is brought to professional attention by family members after marked weight loss (or failure to make expected weight gains) has occurred. If individuals seek help on their own, it is usually because of distress over the somatic and psychological sequelae of starvation. It is rare for an individual with anorexia nervosa to complain of weight loss per se. In fact, individuals with anorexia nervosa frequently either lack insight in to or deny the problem. It is therefore often important to obtain information from family members or other sources to evaluate the his to ry of weight loss and other features of the illness. Associated Features Supporting Diagnosis the semi-starvation of anorexia nervosa, and the purging behaviors sometimes associated with it, can result in significant and potentially life-threatening medical conditions. The nutritional compromise associated with this disorder affects most major organ systems and can produce a variety of disturbances. When seriously underweight, many individuals with anorexia nervosa have depressive signs and symp to ms such as depressed mood, social withdrawal, irritability, insomnia, and diminished interest in sex. Because these features are also observed in individuals without anorexia nervosa who are significantly undernourished, many of the depressive features may be secondary to the physiological sequelae of semi-starvation, although they may also be sufficiently severe to warrant an additional diagnosis of major depressive disorder. Obsessive-compulsive features, both related and unrelated to food, are often prominent. Compared with individuals with anorexia nervosa, restricting type, those with binge-eating/purging type have higher rates of impulsivity and are more likely to abuse alcohol and other drugs. Increases in physical activity often precede onset of the disorder, and over the course of the disorder increased activity accelerates weight loss. Individuals with anorexia nervosa may misuse medications, such as by manipulating dosage, in order to achieve weight loss or avoid weight gain. Individuals with diabetes mellitus may omit or reduce insulin doses in order to minimize carbohydrate metabolism. Prevalence the 12-month prevalence of anorexia nervosa among young females is approximately 0. Development and Course Anorexia nervosa commonly begins during adolescence or young adulthood. The onset of this disorder is often associated with a stressful life event, such as leaving home for college. Younger individuals may manifest atypical features, including denying "fear of fat. Clinicians should not exclude anorexia nervosa from the differential diagnosis solely on the basis of older age. Many individuals have a period of changed eating behavior prior to full criteria for the disorder being met. Some individuals with anorexia nervosa recover fully after a single episode, with some exhibiting a fluctuating pattern of weight gain followed by relapse, and others experiencing a chronic course over many years. Death most commonly results from medical complications associated with the disorder itself or from suicide. Individuals who develop anxiety disorders or display obsessional traits in childhood are at increased risk of developing anorexia nervosa. His to rical and cross-cultural variability in the prevalence of anorexia nervosa supports its association with cultures and settings in which thinness is valued. There is an increased risk of anorexia nervosa and bulimia nervosa among first-degree biological relatives of individuals with the disorder. Concordance rates for anorexia nervosa in monozygotic twins are significantly higher than those for dizygotic twins. The degree to which these findings reflect changes associated with malnutrition versus primary abnormalities associated with the disorder is unclear. Cuiture-R elated Diagnostic issues Anorexia nervosa occurs across culturally and socially diverse populations, although available evidence suggests cross-cultural variation in its occurrence and presentation. The presentation of weight concerns among individuals with eating and feeding disorders varies substantially across cultural contexts. Within the United States, presentations without a stated intense fear of weight gain may be comparatively more common among Latino groups. Mild anemia can occur, as well as thrombocy to penia and, rarely, bleeding problems.
Consistency in enforcing the consequences is essential if positive outcomes are to be achieved symptoms at 6 weeks pregnant synthroid 200 mcg discount. Explore feelings medicine lake montana purchase synthroid 50mcg, and help the client seek more appropriate ways of dealing with them treatment 6th nerve palsy purchase cheapest synthroid and synthroid. Positive reinforcement enhances self-esteem and promotes repetition of desirable behaviors treatment effect definition generic synthroid 100 mcg online. Help the client recognize that he or she must accept the con sequences of own behaviors and refrain from attributing them to others medications known to cause pill-induced esophagitis cheap synthroid 75 mcg otc. Client must accept responsibility for own behaviors before adaptive change can occur treatment plans for substance abuse purchase synthroid 50 mcg amex. Help the client identify positive aspects about self symptoms 0f parkinsons disease order synthroid 75mcg overnight delivery, recognize accomplishments medicine hat mall purchase 125mcg synthroid free shipping, and feel good about them. As self-esteem is increased, client will feel less need to manipulate others for own gratification. Long-term Goal By time of discharge from treatment, client will be able to ac quire 6 to 8 hours of uninterrupted sleep without sleeping medication. Hyperactivity increases and ability to achieve sleep and rest are hindered in a stimulating environment. Provide structured schedule of activ ities that includes established times for naps or rest. Accurate baseline data are important in planning care to help client with this problem. A structured schedule, including time for naps, will help the hyperactive client achieve much-needed rest. Observe for signs such as increasing rest lessness, fine tremors, slurred speech, and puffy, dark circles under eyes. Client can collapse from exhaustion if hyperactiv ity is uninterrupted and rest is not achieved. Before bedtime, provide nursing measures that promote sleep, such as back rub; warm bath; warm, nonstimulating drinks; soft music; and relaxation exercises. Administer sedative medications, as ordered, to assist client achieve sleep until normal sleep pattern is res to red. Client is dealing openly with fears and feelings rather than manifesting denial of them through hyperactivity. Anxiety may be regarded as patholog ical when it interferes with social and occupational functioning, achievement of desired goals, or emotional comfort (Black & Andreasen, 2011). Obsessions are defned as recurrent and persistent thoughts, impulses, or images experienced as intrusive and stressful. Compulsions are identifed as repetitive, ritualistic behaviors that the individual feels compelled and driven to perform, in an effort to decrease feelings of anxiety and discomfort. Selected types of anxiety, obsessive-compulsive, and related disorders are presented in the following sections. Panic Disorder Panic disorder is characterized by recurrent panic attacks, the onset of which are unpredictable, and manifested by intense apprehen sion, fear, or terror, often associated with feelings of impending doom, and accompanied by intense physical discomfort. The symp to ms come on unexpectedly; that is, they do not occur imme diately before or on exposure to a situation that usually causes anxiety (as in specifc phobia). The individual often experiences varying degrees of nervousness and apprehension between attacks. Generalized Anxiety Disorder this disorder is characterized by persistent, unrealistic, and excessive anxiety and worry, which have occurred more days than not for at least 6 months. The symp to ms cause clinically signif cant distress or impairment in social, occupational, or other important areas of functioning. Agoraphobia the individual with agoraphobia experiences fear of being in places or situations from which escape might be diffcult or in which help might not be available in the event that panic symp to ms should occur. It is possible that the individual may have experienced the symp to m(s) in the past and is preoccupied with fears of their recurrence. In extreme cases, the individual is un able to leave his or her home without being accompanied by a friend or relative. If this is not possible, the person may become to tally confned to his or her home. Social Anxiety Disorder (Social Phobia) Social anxiety disorder is an excessive fear of situations in which a person might do something embarrassing or be evaluated nega tively by others. In some instances, the fear may be quite defned, such as the fear of speaking or eating in a public place, fear of using a public rest room, or fear of writing in the presence of others. In other cases, the social phobia may involve general social situations, such as saying things or answering questions in a manner that would provoke laughter on the part of others. Exposure to the phobic situation usually results in feelings of panic anxiety, with sweating, tachycardia, and dyspnea. Specific Phobia Specifc phobia is identifed by fear of specifc objects or situations that could conceivably cause harm. Anxiety, Obsessive-Compulsive, and Related Disorders 171 Exposure to the phobic stimulus produces overwhelming symp to ms of panic, including palpitations, sweating, dizziness, and diffculty breathing. These obsessions and compulsions serve to prevent extreme anxiety on the part of the individual. It may begin in childhood but more often begins in adolescence or early adulthood. The course is usually chronic and may be complicated by depression or substance abuse. Body Dysmorphic Disorder Body dysmorphic disorder is characterized by the exaggerated be lief that the body is deformed or defective in some specifc way. The most common complaints involve imagined or slight faws of the face or head, such as wrinkles or scars, the shape of the nose, excessive facial hair, and facial asymmetry (Puri & Treasaden, 2011). Other complaints may have to do with some aspect of the ears, eyes, mouth, lips, or teeth. Some clients may present with complaints involving other parts of the body, and in some in stances, a true defect is present. The impulse is preceded by an increasing sense of tension and results in a sense of release or gratifcation from pulling out the hair. The most common sites for hair pulling are the scalp, eyebrows, and eye lashes but may occur in any area of the body on which hair grows. These areas of hair loss are often found on the opposite side of the body from the dominant hand. Pain is seldom reported to ac company the hair pulling, although tingling and pruritus in the area are not uncommon. The disorder is relatively rare but occurs more often in women than it does in men. Individuals with this disorder collect items until virtually all sur faces within the home are covered. There may be only narrow pathways, winding through stacks of clutter, in which to walk. Some individuals also hoard food and animals, keeping dozens or hundreds of pets, often in unsanitary conditions (The Mayo Clinic, 2011). The severity of the symp to ms, regardless of when they begin, appears to become more severe with each decade of life. Anxiety Disorder Due to Another Medical Condition the symp to ms of this disorder are judged to be the direct physi ological consequence of another medical condition. Symp to ms may include prominent generalized anxiety symp to ms, panic attacks, or obsessions or compulsions. Medical conditions that have been known to cause anxiety disorders include endocrine, cardiovascular, respira to ry, metabolic, and neurological disorders. Biochemical: Increased levels of norepinephrine have been noted in panic and generalized anxiety disorders. Abnormal elevations of blood lactate have also been noted in clients with panic disorder. Decreased levels of sero to nin have been implicated in the etiology of obsessive-compulsive Anxiety, Obsessive-Compulsive, and Related Disorders 173 disorder. Alterations in the sero to nin and endogenous opi oid systems have been noted with trichotillomania. The sero to nergic system may also be a fac to r in the etiology of body dysmorphic disorder. This can be reflected in a high incidence of comorbidity with major mood disorder and anxiety disorder and the positive responsiveness of the con dition to the sero to nin-specific drugs. Genetic: Studies suggest that anxiety disorders are prevalent within the general population. It has been shown that they are more common among first-degree biological relatives of people with the disorders than among the general popu lation. Trichotillomania has commonly been associated with obsessive-compulsive disorders among first-degree relatives, leading researchers to conclude that the disorder has a possible hereditary or familial predisposition. Neuroana to mical: Structural brain imaging studies in patients with panic disorder have implicated pathological involvement in the temporal lobes, particularly the hippocampus (Sadock & Sadock, 2007). In individuals with hoarding disorder, neu roimaging studies have indicated less activity in the cingulate cortex, the area of the brain that connects the emotional part of the brain with the parts that control higher-level thinking (Saxena, 2013). Medical or Substance-Induced: Anxiety disorders may be caused by a variety of medical conditions or the ingestion of various substances. Psychodynamic Theory: the psychodynamic view focuses on the inability of the ego to intervene when conflict occurs between the id and the superego, producing anxiety. For various reasons (unsatisfac to ry parent-child relationship, conditional love, or provisional gratification), ego develop ment is delayed. If developmental defects in ego functions compromise the capacity to modulate anxiety, the individual resorts to unconscious mechanisms to resolve the conflict. Overuse or ineffective use of ego defense mechanisms results in maladaptive responses to anxiety. Cognitive Theory: the main thesis of the cognitive view is that faulty, dis to rted, or counterproductive thinking pat terns accompany or precede maladaptive behaviors and emotional disorders (Sadock & Sadock, 2007). If there is a disturbance in this central mechanism of cognition, there is a consequent disturbance in feeling and behavior. There is a loss of abil ity to reason regarding the problem, whether it is physical or interpersonal. The individual feels vulnerable in a given situation, and the dis to rted thinking results in an irrational appraisal, fostering a negative outcome. Learning Theory: Phobias may be acquired by direct learn ing or imitation (modeling). In the case of phobias, when the individual avoids the phobic object, he or she escapes fear, which is indeed a powerful reinforcement. Life Experiences: Certain early experiences may set the stage for phobic reactions later in life. Some researchers be lieve that phobias, particularly specific phobias, are symbolic of original anxiety-producing objects or situations that have been repressed. Some studies have shown a possible correlation between trichotil lomania and body dysmorphic disorder and a his to ry of childhood abuse. Repetitive, obsessive thoughts, common ones being related to violence, contamination, and doubt; repetitive, compulsive performance of purposeless activity, such as hand washing, counting, checking, to uching (obsessive-compulsive disorder). Marked and persistent fears of specific objects or situations (specific phobia), social or performance situations (social anxiety disorder), or being in a situation from which one has difficulty escaping (agoraphobia). Having the exaggerated belief that the body is deformed or de fective in some specific way (body dysmorphic disorder). Common Nursing Diagnoses and Interventions (Interventions are applicable to various health-care settings, such as inpatient and partial hospitalization, community outpatient clinic, home health, and private practice. Long-term Goal By time of discharge from treatment, client will be able to recog nize symp to ms of onset of anxiety and intervene before reaching panic stage. Presence of a trusted individual provides client with feeling of security and assurance of personal safety. Use simple words and brief messages, spoken calmly and clearly, to explain hospital experiences to client. In an intensely anxious situation, client is unable to comprehend anything but the most elementary communication. If hyperventilation occurs, assist the client to breathe in to a small paper bag held over the mouth and nose. The client should take 6 to 12 natural breaths, alter nating with short periods of diaphragmatic breathing. This Anxiety, Obsessive-Compulsive, and Related Disorders 177 technique should not be used with clients who have coronary or respira to ry disorders, such as coronary artery disease, asthma, or chronic obstructive pulmonary disease. Keep the immediate surroundings low in stimuli (dim lighting, few people, simple decor). When level of anxiety has been reduced, explore with the client possible reasons for occurrence. Recognition of precipitating fac to r(s) is the first step in teaching the client to interrupt escalation of the anxiety. Teach the client signs and symp to ms of escalating anxiety and ways to interrupt its progression. Relaxation techniques result in a physiological response opposite that of the anxiety response, and physical activities discharge excess energy in a healthful manner. Client is able to maintain anxiety at level in which problem solving can be accomplished. Client is able to demonstrate techniques for interrupting the progression of anxiety to the panic level. Long-term Goal By time of discharge from treatment, client will be able to function in the presence of the phobic object or situation without expe riencing panic anxiety. Discuss reality of the situation with client in order to recognize aspects that can be changed and those that cannot. Client must accept the reality of the situation (aspects that cannot change) before the work of reducing the fear can progress. Include client in making decisions related to selection of alter native coping strategies. If the client elects to work on elimination of the fear, the techniques of desensitization may be employed. This is a sys tematic plan of behavior modification, designed to expose the individual gradually to the situation or object (either in reality or through fantasizing) until the fear is no longer experienced. Fear is decreased as the physical and psychological sensations diminish in response to repeated exposure to the phobic stimulus under nonthreat ening conditions. Encourage client to explore underlying feelings that may be contributing to irrational fears. Help client to understand how facing these feelings, rather than suppressing them, can result in more adaptive coping abilities. Verbalization of feelings in a nonthreatening environment may help client come to terms with unresolved issues. Client does not experience disabling fear when exposed to phobic object or situation. Client verbalizes ways in which he or she will be able to avoid the phobic object or situation with minimal change in lifestyle. Client is able to demonstrate adaptive coping techniques that may be used to maintain anxiety at a to lerable level. Long-term Goal By time of discharge from treatment, client will demonstrate abil ity to cope effectively without resorting to obsessive-compulsive behaviors or increased dependency. Try to determine the types of sit uations that increase anxiety and result in ritualistic behaviors. Sudden and complete elimination of all avenues for dependency would create intense anxiety on the part of the client. Positive reinforcement enhances self-esteem and en courages repetition of desired behaviors. Client may be unaware of the relationship between emotional problems and compulsive behaviors. Provide structured schedule of activities for the client, includ ing adequate time for completion of rituals. Gradually begin to limit amount of time allotted for ritualistic behavior as client becomes more involved in other activities. Anxiety is minimized when client is able to replace ritualistic behaviors with more adaptive ones. Posi tive reinforcement enhances self-esteem and encourages repetition of desired behaviors. Encourage recognition of situations that provoke obsessive thoughts or ritualistic behaviors. Knowledge and practice of coping techniques that are more adaptive will help the client change and let go of maladaptive responses to anxiety. Client is able to verbalize signs and symp to ms of increasing anxiety and intervene to maintain anxiety at manageable level.
This video follows the process of a therapy group of adolescent girls at a summer residential camp for disturbed children symptoms 38 weeks pregnant buy cheap synthroid online. The focus is on three girls with problems ranging from cerebral palsy to depression following years of sexual abuse medications joint pain purchase cheap synthroid line. It shows how an intensive group experience helps change behavior and self-perception medications on a plane cheap synthroid 200mcg. This film illustrates procedures that can help autistic children develop greater awareness of other people and open the door for greater communication medications zetia discount 125mcg synthroid free shipping. This film shows how genetic diseases are passed on to future generations and discusses genetic counseling and the moral questions this counseling raises treatment diverticulitis cheap synthroid 75mcg without a prescription. This award-winning documentary film illustrates behavioral techniques used in helping a year old develop self-control skills everlast my medicine order synthroid online. This film unflinchingly examines the self-destructive behavior of severely retarded individuals and treatment programs to protect them from themselves medicine stick generic synthroid 25mcg without prescription. Chapter 15: Disorders of Childhood and Adolescence 269 cooperative efforts of the staff and the therapist are viewed as the primary treatment mode treatment of pneumonia cheap 25 mcg synthroid mastercard. Silence of the Heart is an excellent, moving movie (now on video) starring a young Charlie Sheen and Chad Lowe dealing with issues of suicide and its effects on family and friends; delves in to copycat suicides. More than 5 million Americans have eating disorders, characterized by physically and/or psychologically harmful eating patterns 3. Subtypes: a) Restricting type loses weight through dieting or exercising; b) Binge-eating/purging type loses weight through self-induced vomiting, laxatives, or diuretics. Physical complications: cardiac arrhythmias, low blood pressure, lethargy, and irreversible osteoporosis 4. Associated characteristics: obsessive-compulsive behaviors and certain personality characteristics 5. Course and outcome a) Approximately 44 to 50 percent of individuals treated for anorexia recover completely b) Mortality rate primarily from cardiac arrest or suicide ranges from 5 to 20 percent C. Bulimia nervosa: recurrent episodes of binge eating high caloric foods at least twice a week for three months, during which the person loses control over eating. Differs from binge-eating/purging anorexia: for anorexia, weight is under minimally expected levels 2. Subtypes a) Purging type: individual regularly vomits or uses laxatives, diuretics, or enemas b) Nonpurging type: excessive exercise or fasting are used to compensate for binges. Prevalence rate is 3 percent of women in the United States; few males exhibit the disorder. Physical complications: erosion of to oth enamel, dehydration, swollen parotid glands, and lowered potassium, which can weaken the heart and cause arrhythmia and cardiac arrest 5. Chapter 16: Eating Disorders and Sleep Disorders 271 a) Comorbid mood disorders are common b) Characteristics of borderline personality. Course and outcome a) Onset generally later than for anorexia (late adolescence or early adulthood) b) Follow-up studies tend to find almost 70 to 75 percent remission D. Prevalence a) One and one-half times more likely for females than males b) Range estimated at from 0. Associated characteristics: comorbid features include major depression, obsessive compulsive personality disorder, and avoidant personality disorder. Course and outcome a) Onset typically late adolescence or early adulthood b) Most individuals make a full recovery even without treatment, but weight is likely to remain high E. Determined by social, gender, psychological, familial, cultural, and biological fac to rs. Societal influences: social desirability of thinness in women in western culture C. Family influences: a) Family interactions characterized by parental control, emotional enmeshment, and conflicts and tensions not openly expressed b) Maternal over-protectiveness, parental rejection c) these findings problematic: case studies, and may be reaction to eating problem, not its cause 2. Peers or family members criticize weight, encourage dieting, glorify ultra-slim models 3. Peer relationships can serve as buffer to eating disorders or produce pressure to lose weight D. African Americans ignore white media messages equating thinness with beauty, more likely than white American women to be satisfied with their body shape and to feel that beauty stems from personality not thinness 4. Anorexics are often described as perfectionistic, obedient, good students, excellent athletes, and model children; emphasis on weight allows them to have control over an aspect of their lives. Prevention programs in schools: aimed at reducing the incidence of eating disorders and disordered eating patterns. Focus on weight gain (by feeding tube, contingent reinforcement for weight gain, or both 2. Cognitive-behavioral and family therapy sessions common after weight gain, but relapse and continued obsession with weight are common. Initially assessed for conditions that may have resulted from purging, including cardiac and gastrointestinal problems. Treatment: psychotherapy, cognitive-behavioral treatment, and antidepressant medications 3. Treatments for anorexia and bulimia involve interdisciplinary teams that include physicians and psychotherapists D. Can involve primary insomnia, primary hypersomnia, narcolepsy or breathe related disorders 3. Circadian rhythm sleep disorder is a pattern of sleep disruption caused by the disruption of the biological sleep-wake cycle B. Etiology of parasomnias such as nightmare disorder, sleep terror and sleepwalking disorders is unknown. Psychological techniques such as relaxation or stimulus control and change in habits D. Consider the physical complications that can arise from anorexia nervosa and why it is difficult to overcome. Delineate other characteristics and mental disorders that are associated with anorexia nervosa. Discuss the characteristics of bulimia nervosa, as well as its physical complications, associated features, and course and outcome. Describe the risk fac to rs for and etiology of eating disorders and evaluate the degree to which society creates eating disorders. Compare the attitudes to ward weight of European American and African American females. Compare the treatments for anorexia nervosa, bulimia nervosa, and binge-eating disorder. Discuss the characteristics, etiology, and treatment of primary sleep disorders (pp. A major irony of anorexia nervosa and bulimia nervosa are that they occur in times and places of relative affluence (consider the "vomi to ria" of ancient Rome where wealthy Romans would go to purge after binging on lavish feasts). Such a pattern would logically suggest that these eating disorders are socially and culturally influenced. A team of investiga to rs at the Howard Hughes Medical Institute and the University of Texas Southwestern Medical Center isolated the hormones, which they call orexin A and orexin B (orexis means "appetite" in Greek). Anorexia and bulimia are difficult disorders to deal with, even for professionals; typically waiting it out is not an option, while insisting that the person get help is likely to result in withdrawal. You may want to encourage the person to contact you when there is the need to talk to someone. However, there is a lot to gain by the process and a lot to lose if the choice is made to continue the existing behaviors. Chapter 18 discusses legal and ethical issues involved in providing therapy to persons who do not want to accept treatment. As discussed in the chapter, the first step in treating anorexia is weight gain, and often this means use of a feeding tube to force feed the patient. The insidious nature of anorexia creates strong resistance to weight gain and all strategies to promote weight gain, even in the face of permanent, lifelong physical ailments and even death. Have each student write on a piece of paper any sleep problems they have had in the recent past with sleep. At the end of lecture give names and contact information of professionals at your school or in the community who specialize in sleep disorders. In small groups, have students put to gether presentations that demonstrate the effect of the media on body image and eating disorders, then have them present a plan to counteract these powerful forces. After completing the presentations, the class as a whole, could design an intervention to present to junior high school and high school classes to educate students about the problem and prevention. Responses from the entire class can be analyzed statistically and compared with research presented in the text. The results of the survey and data analysis can be used to develop presentations for local schools and other community organizations. A large-scale (N = 3,175) survey of middle-school children found that more than 40 percent reported feeling fat and wishing to lose weight. Among girls, whose average age was 12, 43 percent had dieted, 11 percent had fasted, and 6 percent had made themselves vomit to lose weight (Childress et al. It involves a tendency to restrain oneself from eating for fear of gaining weight. They diet frequently and, when feeling susceptible to stress or negative emotions, binge rather than eat normally. It is useful in helping students look at their attitudes and behaviors relevant to eating, but many other sources of information are needed before concluding that high scorers have a problem. What is the maximum amount of weight (in pounds) that you have ever lost within one monthfi Add your to tal points: If your to tal score is 14 or more points, you have a tendency to be a restrained eater. Reprinted with permission from the American Psychological Association and the author. This documentary shows interviews with four anorexic adolescent girls who describe their self-starvation and their attempts to overcome their obsession with thinness. Provides information about anorexia and follows a young women as she battles anorexia. Effective with depression; may alter cortisol levels; concern over side effects; drugs used instead B. Moniz (1930s): destroying certain brain connections (particularly in frontal lobes) could disrupt psychotic thought patterns and behaviors 2. Procedures include prefrontal and transorbital lobo to my, lobec to my (removal of portions of frontal lobe), electrical cauterization; videolaserscopy operates on extremely small areas 3. Scientific and ethical objections; abandoned except for tumors; drugs used instead C. Antianxiety drugs (minor tranquilizers) a) Barbiturates: serious side effects, addiction b) Meprobamate (Propanediol) and benzodiazepines (Librium, Valium): block synaptic transmission; safer, but still cause addiction, overreliance 2. Psychoanalysis: uncovering repressed material to achieve insight; inappropriate for children and for nonverbal and schizoid adults 1. Effectiveness of psychoanalysis a) Impossibility of operational definitions makes confirmation difficult b) Questions about symp to m substitution in nonanalytic therapies c) Declining use in future is predicted B. Person-centered therapy (Rogers): acceptance, empathy, unconditional positive regard; emphasis on relationship 2. Existential analysis: philosophical encounter; case studies but little empirical support for effectiveness 3. Systematic desensitization (Wolpe): anxiety reduction through relaxation paired with steps in anxiety hierarchy; highly effective 2. Flooding and implosion: anxiety induced and then extinguished in real life (flooding) or imagination (implosion) a) Developers claim they are effective b) Some clients find procedures traumatic 3. Aversive conditioning: undesirable behavior (such as smoking or alcohol use) paired with noxious stimulus a) Rapid smoking produces nausea and avoidance b) Covert sensitization (imagined disgusting scenes associated with unwanted behavior) B. Token economies: to kens for desirable behavior exchanged for reinforcers; used in institutional settings 2. Punishment: suppresses self-destructive behavior a) Electric shock to suppress self-destructive behavior b) Ethical issues led to decline in use C. Cognitive-behavioral therapy: change irrational thoughts, teach coping skills and problem solving techniques 1. Health psychology: goal of changing lifestyles to prevent illness or to enhance quality of life 1. Biofeedback: information about au to nomic functions and reward for changing functions in desired direction 2. General strategies a) Establish priorities b) Avoid stressful situations c) Take time out for yourself d) Exercise regularly e) Eat right f) Make friends g) Learn to relax V. Recent survey suggests movement to ward integration and cognitive, away from psychoanalysis and transactional analysis B. Meta-analysis and effect size (large number of studies analyzed by looking at effect sizefi Chapter 17: Therapeutic Interventions 283 d) Reduce isolation and fear e) Provide strong social support 3. Communications approach (Satir, Haley) a) Identify present patterns b) Work for changes in communication 3. Therapeutic eclecticism: process of selecting concepts, methods, and strategies from a variety of current theories that work 1. Openness and flexibility; but can encourage indiscriminate, haphazard, inconsistent use of therapeutic techniques and concepts B. Few studies exist on empirically supported treatments with minority populations B. Guidelines are suggested for working with particular groups, but they should not be adhered to rigidly. Asian Americans and Pacific Islanders: be aware of potential social stigma of seeing a therapist; psychological conflicts may be expressed via somatic complaints and/or other socially acceptable issues; reluctance to self-disclose/ express feelings may be due to cultural fac to rs, not psychopathology; explain purpose, expectations, and process of therapy, and use action-oriented, problem-solving approach. American Psychological Association endorses principle of properly trained psychologists prescribing medication 4. Primary prevention: reduce the number of new cases of disorders a) Head Start is one example b) Munoz and colleagues (1995) report communitywide effort to prevent depression c) Interventions to prevent juvenile delinquency 2. Secondary prevention: shorten duration of mental disorders, but problems exist a) traditional diagnostic methods are often unreliable, provide little insight in to which treatment procedures to use; more specialized diagnostic techniques are needed b) once detected, it may be difficult to decide what therapy is most effective for the specific disorder and patient c) prompt treatment often unavailable 3. Describe and evaluate the use of antianxiety, antipsychotic, antidepressant, and antimanic medications. Discuss why traditional psycho therapy may not be effective with individuals from non-Western cultures and ethnic minority groups. Describe the goals and techniques of psychoanalysis and post-Freudian psychoanalytic therapy. Describe the therapies based on the humanistic/existential perspective, including person-centered therapy, existential analysis, and gestalt therapy. Describe the therapeutic techniques based on classical conditioning, including systematic desensitization, flooding and implosion, and aversive conditioning. Describe the therapeutic techniques based on operant conditioning, including to ken economies and punishment. Discuss the goal of health psychology and describe the techniques used to promote lifestyle changes, including biofeedback. Describe the common components and types of group therapy; evaluate the effectiveness of group therapy. Describe the functions of couples and family therapy, and the different emphases of the communications and systems approaches. Consider the issues raised with respect to culturally diverse populations and psychotherapy. Discuss the changes in mental health service delivery caused by managed health care.
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