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Dr. Julie M. Mullany – Postdoctoral Resident Psychological Services Center St. George’s University, Grenada West Indies Intro : my background & experience Prior Counseling Services work & collaboration with: Wellness Education Services – nutritionists, dieticians Student Health Services – medical perspective Eating Disorder Treatment Team work Goal of today’s Presentation is: To provide information about body image & Eating Disorders (focusing on mainly just Anorexia & Bulimia for purposes today) as well as insight into some treatment approaches. Will also review appropriate ways to talk to your patients in a way that encourages and models attitudes and behaviors that help prevent eating disorders and body image issues and increase healthy self-esteem. What is body image? “the picture of our body which we form in our mind” It involves our perception, imagination, emotions, and physical sensations about our bodies Changes / fluctuates throughout life Can be positive or negative! Psychological in nature o o o Influenced by self-esteem Influenced by what is expected culturally Both men and women can suffer from body image dissatisfaction. (not liking one’s body or specific body parts) Body image can help form self-image Culturally some of us learn that how we look defines who we are So…the worse we feel about our body, the worse we feel about ourselves Self-esteem = how worthy one feels Media – often values an unattainable level of thinness Culture – can vary based upon where you’re from Interpersonal messages – what values do you hear from friends, family members, partners? Personal – what messages do you tell yourself? Diseases/health concerns – ex) cancer, pregnancy Culture – Think about the US - What are images of successful men/women valued in US culture? What does that culture say about heavy vs. thin, muscular vs. lean? Culture of “shame” around body image Size discrimination Fat stigma Hatred of fat prejudice Personal - What personal characteristics contribute to a negative body image? Perfectionism Low self-esteem All or nothing thinking Difficulty focusing on positive qualities “Life would be better if…” o o o o o o o Listen to your body Be realistic about size, appearance Exercise regularly in an enjoyable way Expect normal weekly and monthly changes in weight and shape Work towards self acceptance and self forgiveness Ask for support and encouragement from friends, family, etc. Decide how to spend your energy: -pursuing the “perfect body image” or enjoying life! o o o o o o o o o Eating disorders are illnesses with a biological basis that are often influenced by emotional, cultural, environmental and societal factors In the US alone there are over 10 million females and 1 million males struggling with anorexia and / or bulimia There are millions of others that struggle with binge eating disorder as well ED’s are the no. # 1 cause of death amongst all psychiatric disorders 3 types were classified in the old DSM-IV – Anorexia, Bulimia, & ED NOS (DSM-5 allows for more broader classifications) BIOLOGY: current research indicates that brain chemistry is altered in individuals with ED’s ENDORPHINS released when restricting and bingeing occurs GENETICS play a role: family members with ED’s, other addictions or mental illness CULTURAL/FAMILIAL INFLUENCE: focus on weight, appearance, body image related to self-worth o ENVIRONMENTAL: change in portion sizes, unhealthy choices, culture of convenience & the decrease in activity o SOCIETAL: thin messages, fit/healthy skewed, models with ED’s, magazines digitally enhancing and altering photos, women’s progression in work force often still based on looks over ability o CO-OCCURRING / CO-MORBID DISORDERS such as depression, anxiety, bipolar disorder, OCD, low self-esteem, self-injury, substance abuse o EMOTIONAL TRAUMA: physical, emotional, sexual abuse survivors, trauma, grief (sense of control) o Utilizes ED as a MEANS OF COPING and surviving, control Began as white middle to upper class female disease – which led to a major paradigm shift ED’s currently do not discriminate Males, other ethnicities and races as well as economic status & sexual orientation ED’s can be seen in those as young at 6 years old to as old as 70 + Increase occurring for the first time with middle aged women Increase in instances of ED’s among gay men Prevalence of ED’s with women in Substance Abuse recovery – Athletes Dieting or restricting food o Purging – self-induced vomiting, laxatives, diuretics o Exhaustion or chronic fatigue o Excessive weight loss o Loss of menses o Changes in mood o Lack of motivation o Decreased concentration o Fainting, dizziness or light-headedness o Isolation/withdrawal from peers, or activities o Low potassium Electrolyte Imbalance Heart attack Esophageal rupture Intestinal problems and disorders Hair loss Hair growth (Lanuga) Lower than normal bone destiny (Osteopenia) ..a precursor to bone disease (Osteoporosis) Anorexia is disorder in which someone refuses to eat, even though they may be hungry. They choose not to eat because they are afraid to gain weight, typically have a distorted body image & carry emotional pain Some physical signs & symptoms specific to Anorexia - severe weight loss - low blood pressure - slow heartbeat - growth of fine hair on body Anorexia: - eats foods with low calories & low fat cutting food into small pieces playing with food rather than eating cooking meals for others, not eating compulsive exercise, skipping meals dressing in layers to hide weight loss becomes more isolated & secretive increasing defensiveness frequently weighing oneself Bulimia is a disorder in which people will eat a large amount of food in a short period of time (binge episode) and then either take laxatives or engage in self-induced vomiting (purging). Overexercise (for both those with anorexia or bulimia) is also considered a form of “purging.” Some physical signs & symptoms specific to bulimia sufferers: - damaged teeth or gums from acid in vomit - persistent sore throat - dehydration Bulimia – - secretive about food - spends time planning next binge - taking many trips to the bathroom after eating - take food or hoard in strange places - compulsive / impulsive eating habits Learn as much as you can about Eating Disorders Voice your concern in a non-judgmental, caring, open and honest manner Serve as a healthy role model to the individual Inform someone else if necessary Assist the individual with referrals/info on where to go for help (individual counseling, nutritionist, group &/or family therapy) Address immediate health problems first Make long term treatment plan: - inpatient treatment - Individual & or group therapy - family therapy - eating disorder education - nutritional counseling - continued medical monitoring For Anorexia and Bulimia: - family therapy - addresses unhealthy family dynamics at play / allows eating patterns & routines to be observed (Maudsley model) - Cognitive behavioral therapy or DBT – can help individuals change the unrealistic negative thoughts they have about their appearance & gradually change destructive eating behaviors - Interpersonal therapy – helps individuals improve quality of their relationships, learn how to address conflicts head-on, expand social network & deal with emotions more effectively Ideally, and proven the most effective – is an Eating Disorder Treatment Team approach: A multi-systemic approach to treatment and includes: o o o o o Mental Health Counseling – individual & group Psychiatry Nutritional Counseling Medical Monitoring Further Linkages and referrals Focus on health rather than weight or looks Do not blame, criticize or judge the patient Check your misconceptions about ED’s Do no minimize or joke, listen & be patient Redefine rather than confront resistance Avoid argumentation or defensiveness Empathize self-efficacy, will-power, selfdetermination & empower the patient Develop discrepancy between their present behavior & patient’s personal goals Do not instantly jump to give advice & opinions Avoid talking in great detail of weight or food & eating habits as these aren’t the real issues but symptoms of deeper, more complex underlying emotional issues (& often trauma) Do not get angry with these individuals Encourage them to seek help but never try to force them to eat Assure them they are not alone, that you care & want to help them in any way you can. Expect reactions of anger or denial – don’t push them but say you are there if they want help Assume cognitive distortions & reasoning errors, don’t assume they know facts, clarify Educate about health risks but utilize warmth, compassion & nurturing empathy Discuss a Team approach w/patient to allow them to feel they have control rather than that they are being controlled Validation and good communication reduces defensiveness & splitting behaviors, increases trust & can provide hope & empowerment One of the biggest changes in the new DSM-5 is the removal of the multiaxial system in place of the establishment of 20 diagnostic classes or categories of mental disorders – categories based on groupings of disorders sharing similar characteristics that are not given particular rank. While the DSM-IV(TR) considered 3 Eating Disorders and were listed under the Axis 1 disorders section: - Anorexia Nervosa - Bulimia - or ED-NOS – has characteristics of both …they are now found in Feeding and Eating Disorders and include more types - allowing for additional diagnostic nuance. This diagnostic category includes the following list of specific Feeding & Eating disorders - Anorexia Nervosa - Bulimia Nervosa - Binge Eating Disorder (lacks purging component) - Pica, Rumination Disorder - Avoidant/Restrictive Food Intake Disorder Note - binge-eating disorder has been taken out of the Appendix & has become its own freestanding diagnosis in the new DSM-5. - Psychological Services Center (PSC) at SGU Campeche Hall (2nd Floor) North & South Wings (473) 439-2277 - Search online at eating disorder websites Consult with counselor, MD, nurse, or PCP Call the National Eating Disorders Association hotline no# - 1-800-931-2237