Eileenkristine



ANOREXIA NERVOSADEFINITIONAnorexia Nervosa-is characterized as a disorder in which people:refuse to maintain a minimally normal weightintense fear gaining weightsignificantly misinterpret their body and its shape-anorexia (“lack of appetite”) is misleading because loss of appetite rarely occurs in the early stage of the disorder. -characterized by a profound disturbance of body image and the relentless pursuit of thinness, often to the point of starvation. -the disorder has been recognized for many decades and has been described in various people with remarkable uniformity. -Psychological issues: have been suggested as contributing to the development of the disorder.feelings of helplessness difficulty in establishing autonomy -two types of episodes of anorexia nervosa: restricting type- people restrict intake but do not regularly engage in binge eating or purging by vomiting or using laxatives or diureticsbinge eating-purging type- people regularly engage in binge eating or purging through self-induced vomiting or the use of laxatives or diureticsBulimic symptoms may occur as a separate disorder (bulimia nervosa) or as part of anorexia nervosa. People with either disorder are excessively preoccupied with weight, food and body shape.EPIDEMIOLOGY-4 percent of adolescent and young adult students-occur in about 0.5 to 1 percent of adolescent girls-occurs 10 to 20 times more often in females than males-prevalence of young women with some symptoms of anorexia nervosa but who do not meet the diagnostic criteria is estimated to be close to 5 percent-initially reported most often among upper class, but recent epidemiological surveys do not show that distribution-most frequent in developed countries-may be seen with greatest frequency among women in professions that require thinness, such as modeling and balletETIOLOGY-higher concordance rates in monozygotic twins than in dizygotic twins-sisters of patients with anorexia nervosa are likely to be afflicted, but this association may reflect social influences more than genetic factors.Biological Factors-Endogenous opioids: may contribute to the denial of hunger in patients with anorexia nervosa. -opiate antagonist: Preliminary studies show dramatic weight gains.-biochemical changes: results in starvation, some of which are also present in depression. These abnormalities are corrected by realimination. hypercortisolemia non suppression by dexamethasoneThyroid function I is suppressed as well. -amenorrhea: produced by starvation. It reflects lowered hormonal levels (lutenizing, follicle-stimulating, and gonadotropin –release hormones). Some anorexia nervosa patents however, become amenorrheic before significant weight loss. Social Factors-Patients with anorexia nervosa find support for their practices in society’s emphasis on thinness and exercise. -Patients have close but troubled relationships with their parents. A recent review found that in families in which children presented with eating disorders, especially binge eating or purging subtypes, there were high levels of hostility, chaos and isolation and low levels of nurturance and empathy. -An adolescent with a severe eating disorder may tend to draw attention away from strained marital relationships.Psychological and Psychodynamic Factors -Anorexia Nervosa appears to be a reaction to the demands requiring adolescents to behave more independently and to increase their social and sexual functioning. -Patients with the disorder substitute their preoccupations, which are similar to obsessions, with eating and weight gain for other, normal adolescent pursuits. -Patients typically lack a sense of autonomy and selfhood. Many experience their bodies as somehow under control of their parents, so that self-starvation may be an effort to gain validation as a unique and special person. Only through acts of extraordinary self-discipline can an anorectic patient develop a sense of autonomy and selfhood. -Psychoanalytic clinicians who treat patients with anorexia nervosa generally agree that these young patients have been unable to separate psychologically from their mothers. The body may be perceived as though it were inhabited by an introject of an intrusive and unempathic mother. Starvation may unconsciously mean arresting the growth of this intrusive internal object and thereby destroying it. -Many anorectic patients feel that oral desires are greedy and unacceptable; therefore, these desires are projectively disavowed. PATHOPHYSIOLOGY-Several computed tomographic (CT) studies reveal enlarged CSF spaces (enlarged sulci and ventricles) in patients with anorexia nervosa during starvation, a finding that is reversed by weight gain. -In one positron emission tomographic (PET) scan study, caudate nucleus metabolism was higher in the anorectic state than after realimentation.-Neurochemically, diminished norepinephrine turnover and activity are suggested by reduced 3-methoxy4-hydroxyphenylglycol (MHPG) in the urine and the cerebrospinal fluid (CSF) of some patients with anorexia nervosa. An inverse relation is seen between MHPG and is associated with decrease in depressionLaboratory Examination-No single laboratory test unconditionally helps to diagnose anorexia nervosa. -A multitude of endocrinological and medical problems can develop secondary to the starvation that occurs with the disorder-A battery of screening laboratory tests is warranted in people who meet the diagnostic criteria for anorexia nervosa. The test include:serum electrolytes with renal function teststhyroid function testsglucose, amylase, and hematological testselectrocardiogramcholesterol level dexamethasone-suppression testcarotene level-Clinicians may find:decreased thyroid hormone and serum glucose levels nonsuppression of cortisol after dexamethasonHypokalemiaincreased blood urea nitrogenhypercholesterolemiaCardiovascular complications hypotension bradycardiaSIGNS AND SYMPTOMSDiagnosis and Clinical Featurespersistent refusal to maintain body weight at or above a minimum expected weight (for example, loss of weight leading to a weight of less than 85 percent of expected weight) failure to gain the expected weight during a period of growth, leading to a body weight less than 85 percent of the expected weight. Patients characteristically fear becoming fat, even when drastically underweightexhibit disturbances of body image; they feel fat or misshapen and often deny their emaciation. postmenarcheal women must have an absence of at least three consecutive menstrual cycles. DSM-IV Diagnostic Criteria for Anorexia NervosaA. Refusal to maintain body weight or above a minimally normal weight for age and height (eg. Weight loss leading to maintenance of body weight less than 85% of that expected; or failure to make expected weight gain during period of growth, leading to body weight gain during period of growth, leading to body weight less than 85% of that expected.B. Intense fear of gaining weight or becoming fat, even though underweightC. Disturbance in the way in which one’s body weight or shape is experienced; undue influence of body weight or shape on self-evaluation, or denial of the seriousness of the current low body weightD. In post-menarchal females, amenorrhea, ie, the absence of at least three consecutive menstrual cycles. (A woman is considered to have amenorrhea if her period occur only following hormone, eg, estrogen, administration)Specify Type:Restricting Type: During the current episode of anorexia nervosa, the person has not regularly engaged in binge eating or purging behavior (ie, self-induced vomiting or the misuse of laxatives, diuretics or enemas)Binge eating/purging type: During the episode of anorexia nervosa, the person has regularly engage in binge eating or purging behavior (ie, self-induced vomiting or the misuse of laxatives, diuretics and enemas) Medical complications of eating disordersRelated to weight loss:Cachexia: loss of fat, muscles mass, reduces thyroid metabolism (low T3 syndrome), cold intolerance, and difficulty in maintaining core body temperatureCardiac: loss of cardiac muscle; small heart; cardiac arrythmias, including atrial and ventricular premature contraction, prolonged His’ bundle transmission (prolonged QT interval), bradycardia, ventricular tachycardia; sudden deathDigestive-gastrointestinal: delayed gastric emptying bloating, constipation, abdominal painReproductive: Amenorrhea, low levels of luteinizing hormone (LH) and follicle-stimulating hormone (FSH)Dermatological: Lanugo (fine babylike hair over body), edema Hematological: LeukopeniaNeuropsychiatric: abnormal taste sensation (zinc deficiency,) apathetic depression, mild cognitive disorderSkeletal: OsteoporosisRelated to purging (vomiting and laxative abuse):Metbolic: Electrolyte abnormalities, particularly hypokalemic, hypochloremic alkalosis; hypomagnesemiaDigestive-gastrointestinal: salivary gland and pancreatic inflammation and enlargement with increase in serum amylase, esophageal and gastric erosion, dysfunctional bowel with haustral dilationDental: Erosion of dental enamel, particularly of front teeth, with corresponding decayNeuropsychiatric: seizure (related to large fluids shifts and electrolyte disturbances), mild neuropathies, fatigue and weakness, mild cognitive disorderDSM-IV -identifies two types of anorexia nervosa:Binge eating-purging is common among patients with anorexia nervosa and develops in up to 50% of them. Those who practice binge eating and purging share many features with people who have bulimia nervosa without anorexia nervosa. Those who binge eat and purge tend to tend to have families in which some members are obese, and they themselves have histories heavier body weights before the disorder than do people with the restricting type. Binge eating-purging people are likely to be associated with substance abuse, impulse control disorders, and personality disorders. People with restricting anorexia nervosa limit their food selection, take in a few calories as possible, and often have obsessive-compulsive traits with respect to food and other matters. The suicide rate is higher in people with the binge eating-purging type of anorexia nervosa than in people with the restricting type.-Both types of people are preoccupied with weight and body image, and both may exercise for hours every day and exhibit bizarre eating behaviors. Both may be socially isolated and have depressive disorder symptoms and diminished sexual interest. Some people with anorexia nervosa may purge but not binge. -intense fear of gaining weight and becoming obese is present in all patients with the disorder and undoubtedly contributes to their lack of interest, in and even resistance to, therapy. -Most aberrant behavior directed towards losing weight occurs in secret. Patients usually refuse to eat with their families or in public places. -They lose weight by a drastic reduction in their total food intake, with a disproportionate decrease in high-carbohydrate and fatty foods.-anorexia: is a misnomer, because loss of appetite is usually rare until in the disorder. -Patients’ passion for collecting recipes and for elaborate meals for others is evidence that they are constantly thinking about food. -Some patients cannot continuously control their voluntary restriction of food intake and so have eating binges:usually occur secretly and often at night self induced vomiting frequently follows an eating binge-Patients lose weight by:abuseing laxatives and even diuretics ritualistic exercisingextensive cycling, walking, jogging, and running are common activities-Patients with the disorder exhibit peculiar behavior about food:hide food all over the house frequently carry large quantities of candies in their pockets and purseswhile eating meals, they try to dispose of food in their napkins or hide it in their pockets.cut their meat into very small pieces and spend a great deal of time rearranging the pieces to their plates.If the patients are confronted with their peculiar behavior, they often deny that their behavior is unusual or flatly refuse to discuss it.-Patients tend to be rigid and perfectionist-Somatic complaints: epigastric discomfort-Compulsive stealing: candies, laxatives, clothes and other items-Poor sexual adjustmenT:adolescent patients- delayed psychosocial sexual developmentadults- markedly decreased interest in sex often accompanies the onset of the disorder. -Premorbid history of an unusual minority of anorexia nervosa patients:promiscuitysubstance abuse, or both do not show a decreased interest in sex during the disorder-Patients usually come to medical attention when their weight loss becomes apparent. As the weight loss grows profound, physical signs appear:hypothermia (as low as 35 ?C)dependent edemabradycardiahypotensionlanugo (the appearance of neonatal- like hair) metabolic changes -Some female patients with anorexia nervosa come to medical attention because of amenorrhea, which often appears before their weight loss is noticeable. -Some patients induce vomiting or abuse purgatives and diuretics:such behavior causes concern about hypokalemic alkalosisimpaired water diuresis may be noted-Electrocardiographic (ECG) changes:flattening or inversion of the T wavesST segment depressionlengthening of the QT interval has been noted in the emanciated stage of anorexia nervosa. ECG changes may also result from potassium loss, which can lead to death.-Gastric dilation is a rare complication of anorexia nervosa. -In some patients, aorotography has shown a superior mesenteric artery syndrome. -People with anorexia nervosa have high rates of comorbid major depressive disorders. Major depressive disorder or dysthymic disorder has been reported in up to 50% of an anorexia nervosa patient.-Patients with anorexia nervosa are often secretive, deny their symptoms, and resist treatment. In almost all cases, relatives or intimate acquaintances must confirm a patient’s history. -The mental status examination usually shows a patient who is alert and knowledgeable on the subject of nutrition and who is preoccupied with food and weight.-A patient must have a thorough general physical and neurological examination. If the patient is vomiting, a hypokalemic alkalosis may be present. Because most patients are dehydrated, clinicians must obtain serum electrolyte levels initially and periodically during hospitalization.ICD- 10-describes anorexia nervosa as a deliberate, severe weight loss caused by the patient.-its causes remain unknown, but the combination of sociocultural and biological factors apparently contributes to the disorders, along with a vulnerable personality and other psychological processes. -Undernutrition produces endocrine and metabolic changes and disturbs bodily functions. Whether the endocrine disorder is completely caused by the eating disorder or whether other factors are also at work is uncertain. Differential Diagnosis-The differential diagnosis of anorexia nervosa is complicated by:parents’ denial of the symptomssecrecy surrounding their bizarre eating ritualsresistance to seeking treatment. -It may be difficult to identify the mechanism of weight loss and the patient’s associated ruminative thoughts about distortions of body image.-Clinicians must ascertain that a patient does not have a medical illness that can account for the weight loss (for example, a brain tumor or cancer). Weight loss, peculiar eating behaviors, and vomiting can occur in several mental disorders. -Depressive disorders and anorexia nervosa have several features in common, such as:depressed feelingscrying spellssleep disturbanceobsessive ruminationoccasional suicidal thoughts. -The two disorders, however, have several distinguishing features:patient with depressive disorder has a decreased appetitepatient with anorexia nervosa claims to have a normal appetite and to feel hungry; only in the severe stages of anorexia nervosa do patients actually have decreased appetite.In contrast to depressive agitation, the hyperactivity seen in anorexia nervosa is planned and ritualistic. The preoccupation with recipes and caloric content of foods and the preparation of gourmets feats is typical of patients with anorexia nervosa but is absent in patients with a depressive disorder. In depressive disorders patients have no intense fear of obesity or disturbance of the body image.-Somatization disorder: Weight fluctuationsvomiting peculiar food handling on rare occasions a patient fulfills the diagnostic criteria for both somatization disorder and anorexia nervosa; in such a case both diagnoses should be made.weight loss in somatization disorder is not as severe as that in anorexia nervosa,nor does a patient with somatization disorder express a morbid fear of becoming overweight, as is common in the anorexia nervosa patient. Amenorrhea for 3 months or linger is unusual in somatization disorder.-schizophrenic patients:delusions about food are seldom concerned with caloric content. More likely, they believe the food to be poisoned. rarely preoccupied with a fear of becoming obesedo not have the hyperactivity that is seen in patients have bizarre eating habits but not the entire syndrome of anorexia nervosa.-bulimia nervosa:a disorder in which episodic binge eating, followed by depressive moods, self-deprecating thoughts, so often self-induced vomiting, occurs while patients maintain their weight within a normal range. seldom lose 15 percent of their weight, but the frequently coexist with anorexia.COURSE AND PROGNOSIS-Onset: between the ages of 10-30 years-Patients outside these age range are not typical, and their diagnoses should be questioned. -usually has its onset in adolescence.- 85 percent of all anorexia nervosa patients-Onset: between the ages 13-20 years-after the age of 13 years, the frequency of onset increases rapidly-maximum frequency at 17 to 18 years of age -Before age 10, some patients were picky eaters or had frequent digestive problems.-increasing reports of the ages of onset of anorexia nervosa are the midteens-5 percent of anorectic patients have the onset of the disorder in the early 20s-Course: varies greatlyspontaneous recovery without treatmentrecovery after a variety of treatmentsa fluctuating course of weight gains followed by relapses a gradually deteriorating course resulting in death caused by complications of starvation. -restricting-type anorexic patients seemed to be less likely to recover that those who were of the binge eating-purging type. -The short-term response of patients to almost all hospital treatment programs is good. -In those who have regained sufficient weight, however, preoccupation with food and body weight often continues.-social relationships are often poor, and depression is often present.-In general, the prognosis is not good. Studies have shown a range of mortality rates from 5 to 18 percent.-Indicators of a favorable outcome:admissions of hungera lessening of denial and immaturityimproved self-esteem-Factors related to poor outcome: childhood neuroticismparental conflictbulimia nervosavomitinglaxative abusevarious behavioral manifestations (such a obsessive-compulsive, hysterical, depressive, psychosomatic, neurotic, and denial symptoms) -30 to 50 percent of patients with anorexia nervosa have symptoms of bulimia nervosa, which usually occur within 1 ? years after the beginning of anorexia nervosa. The bulimic symptoms sometimes precede the onset of anorexia nervosa. -outcome: variable and ranges from spontaneous recovery to a waxing and waning course to death.TREATMENT/ MEDICAL MANAGEMENTHospitalization-The first consideration in the treatment of anorexia nervosa is to restore patients’ nutritional state; dehydration, starvation, and electrolyte imbalances can lead to serious health compromises and, in some cases, death. -The decision to hospitalize a patient is based on:patient’s medical condition degree of structure needed to ensure patient cooperationpatients who are 20 percent below the expected weight for their height are recommended for inpatient programs, and patient programspatients who are 30 percent below their expected weight require psychiatric hospitalization that ranges from 2 to 6 months-Inpatient psychiatric programs generally use a combination of: behavioral management approach individual psychotherapy family education and therapypsychotropic medications-Successful treatment is promoted by:ability of staff members to maintain a firm yet supportive approach to patients, often through a combination of positive reinforcers (praise) and negative reinforcers ( restriction of exercise and purging behavior). flexibility for individualizing treatment to meet patients’ needs and cognitive abilities. Patients must become willing participants for treatment to succeed in long term run.-Most patients are uninterested in psychiatric treatment and even resist it:they are brought to a doctor’s office unwillingly by agonizing relatives or friends.patients rarely accept the recommendation of hospitalization without arguing and criticizing the proposed program.emphasizing the benefits, such as the relief of insomnia and patients’ depressive signs and symptoms, may help persuade the patients to admit themselves willingly to hospital. relatives support and confidence in the physicians and treatment team are essential when firm recommendations must be carried out. Patients’ families should be warned that the patients will resist admission and, for the several weeks of treatment, will make many dramatic pleas for the family’s support to obtain release from the hospital program. Only when risk of death from the complications of malnutrition is likely should be compulsory admission or commitment be obtained. On rare occasions, patients prove that the doctor’s statements about the probable failure of outpatient treatment are wrong. Some patients may gain a specified amount of weight by the time of each outpatient visit, but such a behavior is uncommon, and a period of inpatient care is usually necessary.-The general management of patients with anorexia nervosa during a hospitalized treatment program should take into account the following: Patients should be weighed daily early in the morning after emptying the bladder.The daily fluid intake and the urine output should be recorded. If vomiting is occurring, hospital staff members must monitor serum electrolyte levels regularly and watch for the development of hypokalemia. Because food is often regurgitated after meals, the staff may be able to control vomiting by making the bathroom inaccessible for at least 2 hours after meals or by having a attendant in the bathroom to prevent vomiting. Constipation in these patients is relieved when they begin to eat normally. Stool softeners, but never laxatives. Because of the rare complication of stomach dilation and the possibility of circulatory overload when patients immediately start eating an enormous number of calories, the hospital staff should give the patients about 500ncalories over the amount required to maintain their present weight (usually 1,500 to 2,000 calories a day). It is wise to give these calories in six equal feedings throughout the so that patients need not eat a large amount of food at one sitting. Giving patients a liquid food supplement such as Sustagen may be advisable, because they may be less apprehensive about gaining weight slowly with the formula than by eating food.-After patients are discharged from the hospital, clinicians usually find it necessary to continue outpatient supervision of the problems identified in the patients and their families. Psychotherapy-Most patients with anorexia nervosa require continued interventions after discharge from the hospital or after they are restored to health through outpatient treatment plans. -Because for most patients the onset of the disorder occurs in adolescence, family therapy is part of a comprehensive treatment plan. -Classical psychodynamically oriented therapy has not been useful in early stages of treatment, especially when patients are in a starvation state-Insight-oriented psychotherapies have been helpful to some patients when they have been stabilized.Dynamic Psychotherapy-Dynamic expressive-supportive psychotherapy: Sometimes used in the treatment of patients with anorexia nervosa, but patients’ resistances may make the process difficult and painstaking. Patients view the symptoms as constituting the core of their specialness, therapists must avoid excessive investment in trying to change their eating behaviors. The opening phase of the psychotherapy process must be geared to building a therapeutic alliance. Patients may experience early interpretations as though someone else were telling them what they really feel and thereby minimizing and invalidating their own experiences. Therapists who emphasize with patients’ points of view and take an active interest in what their patients think and feel, however, convey to patients that their autonomy is respected. Psychotherapies must be flexible, persistent, and durable in the face of patients’ tendencies to defeat any efforts to help them.-Cognitive-behavioral approaches:to monitor weight gain and maintenance and to address eating behaviorsexplore other issues related to the disorder-Family therapy: has been used to examine interactions among family members and the disorders’ possible secondary fain for patients.Biological Therapy-cyproheptadine (Perciactin): a drug with antihistaminic and antiserotonergic properties, for patients with restricting type of anorexia nervosa-Amitriptyline (Elavil): has also been reported to have some benefit. -Other medications:clomipramine (Anafranil)pimozide (Orap)chlorpromazine (Thorazine). -fluoxetin (Prozac): have resulted in some reports of gain weight-serotonergic agents: have yielded positive responses. -coexisting depressive disorders should be treated: Concerns exist about the use of tricyclic drugs in low-weight, depressed patients with anorexia nervosa, who may be vulnerable to hypotension, cardiac arrhythmia, and dehydration. Once an adequate nutritional status has been attained, the risks of serious side effects from the tricyclic drugs may decreaseIn some cases the depression improves with weight gain and normalized nutritional status. Rarely, electroconvulsive (ECT) may be beneficial in certain cases of anorexia nervosa and major depressive disorder.BULIMIA NERVOSADEFINITIONBulimia Nervosa-Defined as binge eating combined with inappropriate ways of stopping weight gain. -The recurrent episodes of bulimia nervosa which is more common than is anorexia nervosa, are accompanied by feelings of being out of control. -Social interruption or physical discomfort (abdominal pain or nausea) terminated the binge eating, which is often followed by feelings of guilt, depression, or self disgust.-People with bulimia nervosa also show recurrent compensatory behaviors, such as:purging (self-induced vomiting, repeated laxative or diuretic use)fasting, or excessive exercise- to prevent weight gain-Unlike patients with anorexia nervosa, those with bulimia nervosa may maintain a normal body weight. -binge eating and compensatory behaviors must both occur an average of at least twice a week for 3 moths. -people with bulimia nervosa evaluate themselves predominantly on the basis of body shape and weight. -may not be diagnosed if it occurs exclusively during episodes of anorexia nervosa. -types of bulimia nervosa: purging type of disorder- regularly engage in self-induced vomiting or the misuse of laxatives or diuretics. non-purging type- use other inappropriate compensatory behaviors to prevent weight gain, such as fasting and exercise, but do not purge.EPIDEMIOLOGY-more prevalent than is anorexia nervosa. -1 to 3 percent of young women-more common in women than in men-Occasional binge eating and purging, have been reported in up to 40 percent of college women. -Although bulimia nervosa is often present in normal-weight young women, they sometimes have a history of obesity.ETIOLOGYSocial Factors. -tend to be high achievers and respond to societal pressure to be slender. -depressed and have increased familial depression:families of patients with bulimia nervosa are generally less close and more conflictual than are the families of anorexia nervosa patients. Patients with bulimia nervosa describe their parents as neglectful and rejecting.Psychological Factors. -difficulties with adolescent demands-are more outgoing, angry, and impulsive than are anorexia nervosa patientsTheir difficulties in controlling their impulses are often manifested by substance dependence and self destructive sexual relationships, in addition to the binge eating and purging that are hallmarks of the disorder- Alcohol dependence, shoplifting, and emotional lability (including suicidal attempts) are associated with bulimia nervosa-These patients generally experience their uncontrolled eating as more ego-dystonic than do anorexia nervosa patients and so more readily seek help.- lack superego control -have histories of difficulties in separating from caretakers:manifested by the absence of transitional objects during their early childhood yearssome clinicians have observed that patients with bulimia nervosa use their own bodies as transitional objects. The struggle for separation from a maternal figure is played out in the ambivalence toward foodeating may represent a wish to fuse with the caretakerregurgitating may unconsciously express a wish for separationPATHOPHYSIOLOGY -Some investigators have attempted to associate cycles of binging and purging with various neurotransmitters:Because antidepressants often benefit patients with bulimia nervosa, serotonin and norepinephrine have been implicated. Because plasma endorphin levels are raised in some bulimia nervosa patients who vomit, the feelings of well-being after vomiting that some of theses patients experience may be mediated by raised endorphin levels.-electrolyte abnormalities and various degrees of starvation, although it may not be as obvious as in low-weight patients with anorexia nervosa. -thyroid function remains intact in bulimia nervosa, but patients may show nonsuppression on the dexamethasone-suppression test. -dehydration and electrolyte disturbances are likely to occur in bulimia nervosa patients who regularly purge. -hypomagnesemia and hypermylasemia.-Although not a core diagnostic feature, many patients with bulimia nervosa have menstrual disturbances.-Hypotension and bradycardia occur in some patientsSIGNS AND SYMPTOMSDiagnosis and Clinical FeaturesAccording to DSM-IV, the essential features of bulimia nervosa are recurrent episodes of binge eating; a sense of lack of control over eating during the eating binges; self-induced vomiting, the misuse of laxatives or diuretics, fasting, or excessive exercise to prevent weight gain; persistent self-evaluation unduly influence by body shape and weight.DSM-IV Diagnostic Criteria for Bulimia NervosaA. Recurrent episodes of binge eating. An episode of binge eating is characterized by both of the following:(1) eating in a discrete period of time (eg, within any 2 hour period), an amount of food that is definitely larger than most people would eat during a similar period of time and under similar circumstances(2) a sense of lack of control over eating during the episodes (eg, a feeling that one cannot stop eating or control what or how much one is eating)B. Recurrent inappropriate compensatory behavior in order to prevent weight gain, such as self-induced vomiting; misuse of laxatives, diuretics, enemas, or other medications; fasting; or excessive exercise’C. The binge eating and inappropriate compensatory behaviors both occur, on average, at least twice a week for 3 months.D. Self-evaluation is unduly influenced by body shape and weight.E. The disturbance does not occur exclusively during episodes of anorexia nervosa.Specific type:Purging type: during the current episodes of bulimia nervosa, the person has regularly engage in self-induced vomiting or the misuse of laxatives, diuretics, or enemasNonpurging type: during the current episodes of bulimia nervosa, the person has used other inappropriate compensatory behaviors, such as fasting or excessive exercise, but has not regularly engage in self-induced vomiting or the misuse of laxatives, diuretics, or enemas.-Binging:usually precedes vomiting by about 1 year.patients eat food that is sweet, high in calories, and generally soft or of smooth texture, such as cakes and pastry. some patients prefer bulky foods without regard to taste. food is eaten secretly and rapidly and is sometimes not even chewed-Vomiting:is common and is usually induced by sticking a finger down the throat, although some patients are able to vomit at will. decreases the abdominal pain and the feeling of being bloated allows patients to continue eating without fear of gaining weight. -Depression (postbinge anguish) often follows the episode. -Most patients with bulimia nervosa are within their normal weight range, but some may be underweight or overweight. -These patients are concerned about their body image and their appearance:worry about how others see themconcerned about their sexual attractivenessMost are sexually active, compared with anorexia nervosa patients, who are not interested in sex. -Pica and struggles during meals are sometimes revealed in the histories of patients with bulimia nervosa.-Patients with the purging type of bulimia nervosa may be at risk for certain medical complications, such as:hypokalemia from vomiting or laxative abuse hypochloremic alkalosisgastric and esophageal tears- those who vomit repeatedly, although these complications are rare. -occurs in people with:high rated of mood disorders and impulse control disorderssubstance-related disorders a variety of personality disorders. anxiety disordersbipolar 1 disorderdissociative disordershistories of sexual abuseICD 10. -described as repeated bouts of over-eating and a preoccupation about controlling weight and lead to self-induced vomiting-vomiting produces physical complications, electrolytes, disturbances, and severe weight loss Differential Diagnosis-The diagnosis of bulimia nervosa cannot be made if binge eating and purging behaviors occur exclusively during episodes of anorexia nervosa. In such cases the diagnosis is anorexia nervosa, binge eating-purging type.-Clinicians must ascertain that patients have no neurological disease, such as:epileptic-equivalent seizurecentral nervous system tumorsKluver-Bucy syndrome- visual agnosia, compulsive licking and biting, examination of objects by the mouth, inability to ignore any stimulus, placidity, altered sexual behavior (hypersexuality), and altered dietary habits, especially hyperphagia.Kleine-Levin-periodic hypersomnia lasting for 2 to 3 weeks and hyperphagia. As in bulimia nervosa, the onset is usually during adolescence, but the syndrome is more common in men than in women. Patients with borderline personality disorder sometimes binge eat, but the eating is associated with other sings of the disorder.COURSE AND PROGNOSIS-onset: often later in adolescence than is the onset of anorexia nervosa; may even occur in early adulthood. -Little is known about the long-range course of bulimia nervosa, and the short-term outcome is variable. -have a better prognosis than does anorexia nervosa. -patients with bulimia nervosa who are able to engage in treatment have reported more than 50 percent improvement in binge eating and purging-among outpatients, improvement seems to last more than 5 years. -patients are not symptom free during the periods of improvement-bulimia nervosa is chronic disorder with a waxing and waning course-patients with mild courses have long-term remissions-other patients are disabled by the disorder and have been hospitalized-less than one third of them are doing well at 3-year follow up-more than one third have some improvement in their symptom-one third have poor outcome, with chronic symptoms, within 3 years. -at 5 to 10 years, about half of patients recovered fully from the disorder -20 percent continued to meet full diagnostic criteria for bulimia nervosa-prognosis depends on the severity depends on the purging sequelae-that is whether a patient has electrolyte imbalances and to what degree the frequent vomiting results in esophagitis, amylasemia, salivary gland enlargement, and dental caries.-In some cases of untreated bulimia nervosa, spontaneous remission occurs in 1 to 2 yearsTREATMENT/ MEDICAL MANAGEMENT -Because of the comorbidity of mood disorders, anxiety disorders, and personality disorders with bulimia nervosa, clinicians must factor these additional disorders into the treatment plan.-Most patients with uncomplicated bulimia nervosa do not require hospitalization.-In general, patients with bulimia nervosa are not as secretive about their symptoms as are patients with anorexia nervosa. -outpatient treatment is usually not difficult-psychotherapy is frequently stormy and may be prolonged psychotherapy do surprisingly well. -In some cases- when eating binges are out of control, outpatient does not work, or a patient exhibits such additional psychiatric symptoms as suicidality and substance abuse- hospitalization may become necessary. -In cases of severe purging, resulting electrolyte and metabolic disturbances may necessitate hospitalization.Psychotherapy-cognitive-behavioral psychotherapy:address the specific behaviors surrounding and leading up to eating bingesbehavioral contract and desensitization to the thoughts and feelings that patients with bulimia nervosa have just before binge eating. -psychodynamic, interpersonal, and family therapies can be useful.-Psychodynamic treatment: revealed a tendency to concretize introjective and projective defense mechanism. In a manner analogous to splitting, patients divide food into two categories: items that are nutritious and those that are unhealthy. Food that is designated nutritious may be ingested and retained because it unconsciously symbolizes good introjects. Junk food is unconsciously associated with bad introjects and is, therefore expelled by vomiting, with the unconscious fantasy that all destructiveness, hate, and badness are being evacuated.Patients may temporarily feel good after vomiting because of the fantasized evacuation, but the associated feeling of “being all good” is short-lived because it is based on an unstable combination of splitting and projection.Pharmacotherapy -Antidepressant medications: serotonin reuptake inhibitors such as fluoxetine. based on elevating central 5-hydroxytryptamine levels.reduce binge eating and purging independent of the presence of a mood disorder. Thus, for particularly difficult binge-purge cycles that are not responsive to psychotherapy alone, antidepressants have been successfully used. Imipramine (Tofrnail), desipramine (Nopramin), Trazodone (Desyrel), and monoamine oxidase (MAO) inhibitors effective in decreasing binge eating may be higher (60 to 80 mg a day) than those used for depressive disorders. -In cases of comorbid depressive disorders and bulimia nervosa, medications is helpful. -Carbamazepine (Tegretol) and lithium (Eskalith) have not shown impressive results as treatment for binge eating, but have been used in the treatment of bulimia nervosa patients with comorbid mood disorders, such as bipolar I disorder.EATING DISORDER NOT OTHERWISE SPECIFIEDThe DSM-IV diagnostic classification of eating disorder not otherwise specified is a residual category used for eating disorders that do not meet the criteria for specific eating disorder. Binge eating disorder- that is, recurrent episodes of binge eating in the absence of the inappropriate compensatory behaviors characteristic of bulimia nervosa falls into this category. Such patients are not fixated on body shape and weight.DSM-IV Diagnostic Criteria for eating Disorder not otherwise SpecifiedThe eating disorder not otherwise specified category is for disorders of eating that do not meet the criteria for any specified eating disorder. Examples include:1. for females, all of the criteria for anorexia nervosa are met except the individual has regular menses.2. all of the criteria for anorexia nervosa are met except that, despite significant weight loss, the individual’s current weight is in normal range.3. all of the criteria for bulimia nervosa are met except that the binge eating and inappropriate compensatory mechanisms occur at a frequency of less than twice a week or for a duration of less than three months.4. the regular use of inappropriate compensatory behavior by an individual of normal body weight after eating small amounts of food (eg, self-induced vomiting after consumption of two cookies)5. repeatedly chewing and spitting out, but nor swallowing large amount of food.6. binge eating disorder: recurrent episodes of binge eating in the absence of the regular use of inappropriate compensatory behaviors characteristic of bulimia nervosa.DSM-IV Research Criteria for binge eating disorderA. Recurrent episodes of binge eating. An episode of binge eating is characterized by both of the following:(1) eating in a discrete period of time (eg, within any 2 hour period), an amount of food that is definitely larger than most people would eat in a similar period of time under similar circumstances(2) a snese of lack of control over eating during the episode (eg, a feeling that one cannot stop eating or control what or how much one is eating)B. The binge eating episodes are associated with three (or more) of the following:(1) eating much more rapidly than normal(2) eating until uncomfortably full(3) eating large amounts of food when not feeling physically hungry(4) eating alone because of being embarrassed by how much one is eating(5) feeling disgusted with oneself, depressed, or very guilty after overeatingC. Marked distress regarding binge eating is presentD. The binge eating occurs, on average, at least 2 days a week for 6 months.Note: the method of determining frequency differs from that used for bulimia nervosa; future research should address whether the preferred method of setting a frequency threshold is counting the number of episodes of binge eating. E. the binge eating is not associated with the regular use of inappropriate compensatory behaviors (eg, purging, fasting, excessive exercise) and does not occur exclusively during the course of anorexia nervosa or bulimia nervosa.ICD-10In the category of eating disorder, ICD-10 also includes atypical anorexia, atypical bulimia nervosa, overeating associated with other psychological disturbances, other eating disorders, and eating disorders, unspecified OBESITYDEFINITION-a condition characterized by excessive accumulation of fat in the body-weight exceeds by 20 percent the standard weight -body mass index (BMI):more precise measurement of obesity amount of fat in the body calculated by the following formula: BMI= (body weight in kg)(height in m)?The BMI correlates with morbidity and mortality. In general, a normal BMI is in range of 20 to 25 (fig. 23.3-1 and table 23.3-2)EPIDEMIOLOGY-More than half of people in the United States are obese. -6 times more common among women of lower socioeconomic status than among women of higher socioeconomic status-A similar, although weaker, relationship is found among men-prevalence of obesity increases threefold between ages 20 and 50-weights of men stabilize after age 50 and begin to decline around the age of 60-women continue to gain weight until age 60, at which time their weight begins to decline-Black men and women have a higher prevalence of obesity than do with white people-one third or more of children and adolescents in the United States are too heavy-an obese child has greater risk of becoming an obese adult than does a child of normal weightETIOLOGY-People accumulate fat by eating more calories than are expended as energy-If fat is to be removed from the body, fewer calories must be put in, or more calories must be taken out than are put in. -An error of no more than 10 percent in either intake or output would lead to a 30-pound change in body weight in 1 year.Satiety-the feeling that results when hunger is satisfied. -occurs soon after the beginning of a meal and before the total caloric content of the meal has been absorbed-only one regulatory mechanism controlling food intake-People stop eating at the end of a meal because they have replenished nutrients that have been depleted. People become hungry again when nutrients restored by earlier meals are once again depleted-a metabolic signal, derived from food that has been absorbed, is carried by the blood to the brain, where the signal activates receptor cells, probably in the hypothalamus, to produce satiety. -olfactory system:play a role in satietyExperiments have shown that strong stimulation of the olfactory bulbs in the nose with food odors by using an inhaler saturated with a particular smell produces satiety for that food. This may have implications for therapy of obesity.-Hunger is the consequence of the decreasing strength of this same metabolic signal, secondary to the depletion of critical nutrients.-Appetite is defined as the desire for food, Appetite may be increased by psychological factors such as thoughts or feelings and abnormal appetite my result in abnormal increase of food intake.-A hungry person may eat to full satisfaction when food is available, but appetite can also induce a person to overeat past the point of satiety. Table 23.3-2Desirable Body Mass Index (BMI) in relation to ageAge(years)BMI (kg/m?)19-2425-3435-4445-5455-65>6519-2420-2521-2622-2723-2824-29Genetic factors-The existence of numerous forms of inherited obesity in animals and the ease with which adiposity can be produced by selective breeding make it clear that genetic factors can play a role in obesity. -About 80 percent of patients who are obese have a family history of obesity. -studies show that identical twins raised apart can both be obese, an observation that suggests a hereditary role. Developmental Factors-adipose tissue grows by increase in both cell number and cell size. -Obesity that begins early in life is characterized by adipose tissue within an increased number and size of adipocytes. -Obesity that begins in adult life results solely from an increase in the size of the adipocytes. -In both instances, weight reduction produces a decrease in cell size. T-The greater number and size of adipocytes in patients with juvenile-onset diabetes may be a factor in their widely recognized difficulties with weight reduction and the persistent of their obesity.-The distribution and amount of fat vary in individuals, and fat in different body areas has different characteristics:Fat cells around the waist, flanks, and abdomen (the so called potbelly) are more active metabolically than are in the thigh and buttocks; more common in men and has a higher correlation with cardiovascular disease than does the latter pattern.Women, whose fat distribution is in the thighs and buttocks, may become obsessed in nostrum that are advertised to reduce fat in these areas (so-called cellulite, which is not a medical term); but no externally applied preparation to reduce this fat pattern exist. Men with abdominal fat may attempt to reduce their girth with machines that exercise the abdominal muscles, but exercise has no effect on fat loss.-A hormone called leptin, made by fat cells, acts as a fat thermostat. When the blood level of leptin is low, more fat is consumed; when high, less fat is consumed.Physical Activity Factors-The marked decrease in physical activity in affluent societies seems to be major factor in the rise of obesity as a public health problem. -Physical inactivity restricts energy expenditure and may contribute to increased food intake. -Although food intake increases with increasing energy expenditure over a wide range of energy demands, intake does not decrease proportionately when physical activity falls below minimum level.Other Clinical Factors- Cushing’s disease is associated with a characteristic fat distribution (buffalo adiposity).-Myxedema is associated with weight gain, although not invariably. -Other neuroendocrine disorders include adiposgenital dystrophy (Frohlich’s syndrome), which is characterized by obesity and sexual and skeletal abnormalities. -Some workers have reported that the prolonged use of serotonergic agonists in the treatment of depression is associated with weight gain, but more studies are needed.-Depressed patients are known to have fluctuations in weight.Psychological Factors-specific family histories, precipitating factors, personality structures, unconscious conflicts as causing obesity, people who are overweight may suffer from every conceivable psychiatric disorder and come from a variety of disturbed backgrounds. -obese patients may be characterized as emotionally disturbed persons, who, because of the availability of the over eating mechanism in their environments, have learned to use hyperphagia as a means of coping with psychological problems. PATHOPHYSIOLOGY-Destruction of the ventromedial hypothalamus can produce obesity in animals, but this is probably a very rare cause of obesity in humans. -There is evidence that the central nervous system, particularly in the lateral and ventromedial hypothalamus areas, adjusts to food intake in response to changing energy requirements so as to maintain fat stores at a baseline determined by a specific set point. This set point varies from one person to another and depends on height and body build.SIGNS AND SYMPTOMS -Many obese people report that they overeat when they are emotionally upset, but many non-obese people report similar experiences, and it is difficult to ascertain the specificity for obesity of such short term contingencies. -Reports linking emotional factors and obesity over the long range seem more specific: some obese people lose large amounts of weight when they fall in love and gain weight when they lose a loved one. The habit while eating patterns of many obese people often seem similar to patterns found in experimental obesity, impaired satiety is a particularly important problem. Obese people seem inordinately susceptible to food cues in their environment, to the palatability of foods, and to the ability to stop eating if food is available. Obese people are usually susceptible to all kinds of external stimuli to eating, but they remain relatively unresponsive to the usual internal signals of hunger. Some are unable to distinguish between hunger and other kinds of dysphoria. Differential Diagnosis-night-eating syndrome: people excessively, after they had their evening meal, seems to be precipitated by stressful life circumstances once present, tends to recur daily until the stress is alleviated-binge-eating syndrome (bulimia):characterized by the sudden, compulsive ingestion of very large amounts of food in a very short time, usually with great subsequent agitation and self condemnationappears to represent a reaction to stress in contrast to the night-eating syndrome, however, these bouts of over-eating are not periodic, and they are far more often linked to specific precipitating circumstances.-pickwickian syndrome:exist when a person is 100% over desirable weight has associated respiratory and cardiovascular pathology.-Body Dysmorphic disorder (Dysmorphobia):Some obese people feel that their bodies are grotesque and loathsome and that others view them with hostility and content. This feeling is closely associated with self-consciousness and impaired social functioning. Emotionally healthy obese people have no body image disturbance, and only a minority of neurotic obese people has such disturbances. The disorder is confined mainly to person who have been obese since childhood; even among them, less than half suffer it.COURSE AND PROGNOSIS-Obesity has adverse effects on health and is associated with a broad range of illnesses.-There is a strong correlation between obesity and cardiovascular disorders.-Hypertension (blood pressure higher than 160/95) is 3 times higher for people who are overweight -Hypercholesterolemia (blood cholesterol over 250 mg/dl) is twice as common -Studies show the blood pressure and cholesterol levels can be reduced by weight reduction -Diabetes which has clear genetic determinations can often be reversed with weight reduction, especially type II diabetes (mature-onset or non-insulin-dependent diabetes mellitus). -According to National Institutes of Health data, obese men, regardless of smoking habits, have a higher mortality from colon, rectal, and prostate cancer than do men of normal weight. -Obese women have a higher mortality from cancer of the gallbladder, biliary passages, breast (postmenopause), uterus (including cervix and endometrium), and ovaries than do women of normal weight.Longevity- the greater a person’s degree of overweight, the higher is the person’s risk for death. -a person who reduces weight to acceptable levels has a decline in mortality to normal rates. -Weight reduction may be lifesaving for patients with extreme obesity, defined as weight that is twice the desirable weight. -Such patients may have cardio-respiratory failure, especially when asleep (sleep apnea). -prognosis for weight reduction is poor-course of obesity tends toward inexorable progression-prognosis is particularly poor for those who become obese in childhood. -Juvenile-onset obesity tends to be more ever, more resistant to treatment, and more likely to be associated with emotional disturbance than is adult obesity. TREATMENT/ MEDICAL MANAGEMENT-As many as half of patients routinely treated for obesity by family physicians may develop mild anxiety and depression. - high incidence of emotional disturbances has been reported among obese people undergoing long-term, in-hospital treatment by fasting or severe calorie restriction.-Obese people with extensive psychopathology, those with a history of emotional disturbance during dieting, and those in the midst of a life crisis should attempt weight reduction, if at all, cautiously and under careful supervision.Diet-establish a caloric deficit by bringing intake below output. -simplest way to reduce caloric intake is by means of a low-calorie diet.-best long-term effects are achieved with a balanced diet that contains readily available foods. -most satisfactory reducing diet consists of their usual foods in amounts determined with the aid of tables of food values that are available in standard works. Such a diet gives the best chance of long term maintenance of weight loss achieved by dieting. -Total unmodified fasts:used for short-term weight losshave associated morbidity including orthostatic hypotension, sodium diuresis, and impaired nitrogen balance-Ketogenic diets:high-protein, high-fat diets used to promote weight losshigh cholesterol content and produce ketosisassociated with nausea, hypotension, and lethargy-Many obese people find it tempting to use a novel or even bizarre diet. Whatever effectiveness those diets may have, in large part results to the usual fare, the incentives to overeat are multiplied. -best method of weight loss is a balanced diet of 1100 to 1200 calories. Such a diet can be followed for long periods but should be supplemented with vitamins, particularly iron, folic acid, zinc, and vitamin B6. Exercise-Increased physical activity is frequently recommended as part of a weight-reduction regimen. -caloric expenditure in most forms of physical activity is directly proportional to body weight, obese people expend more calories with the same amount of activity than do people expend more calories with the same amount of activity than do people of normal weight. -increased physical activity may actually cause a decrease in food intake for formerly sedentary people. -This combination of increased caloric expenditure and decreased food intake makes an increase in physical activity a highly desirable feature of any weight-reduction program. -Exercise also helps maintain weight loss. Pharmacotherapy- Drug treatment is effective because it suppresses appetite; but tolerance to this effect may develop after several weeks of use. -An initial trial period of 4 weeks with a specific drug can be used; then, if the patient responds with weight loss the drug can be continued to see whether tolerance develops. If a drug remains effective, it can be dispensed for a longer time until the desired weight is achieved. -The biogenic amines and serotonin are involved in regulating eating behavior. -appetite suppressants:dexfenfluramine (Redux) fenfluramine (Pondimin)these drugs were withdrawn in 1997 because of reports of aortic and mitral valve regurgitation in patients who used these drugs. Amphetamine (Dexedrine) and its congeners, such as methamphetamine (Desoxyn) and phentermine (Adipex-P fastin), work mainly by increasing norepinephrine levels. Impaired eating behavior-Drugs exist that prevent the absorption of certain macronutrients (fat or carbohydrate):Perfluoroctyl bromide coat the gastrointestinal tract inhibiting fat absorption.Other drugs inhibit hydrolysis of carbohydrates or fats so they cannot be absorbed. A new drug is orlistat (Xenical), a nonsystemic pancreatic lipase inhibitor that has been shown to decrease the amount of fat absorbed 30 percent. To be effective, drugs in this category must be used in conjunction with a mildly hypocaloric, low-fat diet to avoid uncomfortable adverse gastrointestinal effects such as oily spotting. A such, drugs with this mechanism of action are ideally coadministered with a behavioral modification program. Surgery-Surgical methods:cause malabsorption of food or reduce gastric volume have been used in people who are markedly obese. -Gastric bypass:a procedure in which the stomach is made smaller by transecting or stapling one of the stomach curvatures. -Gastroplasty:size of the stomach stoma is reduced so that the passage of food slows. Results are successful, although vomiting, electrocyte imbalance, and obstruction may occur. -Lipectomy:surgical removal of fat used for cosmetic reasons and has no effect on weight loss in the long run. Psychotherapy-psychological problems of obese people are varied and there is no particular personality type that is obese. - this treatment has not achieved much success. -there is little evidence that uncovering the unconscious causes of overeating can alter the symptom choice of people who overeat in response to stress. -years after successful weight reduction, most people who overeat under stress continue to do so. -many obese people seem particularly vulnerable to overdependency on a therapist and their inordinate regression that may occur during the uncovering psychotherapies.-Behavior modification:has been the most successful of the psychotherapies considered the method of choicePatients are taught to recognize external cues that are associated with eatingkeep diaries of foods consumed in particular circumstances, such as the movies or while watching television, or during certain emotional states, such as anxiety or depression. develop new eating patterns, such as eating slowly, chewing food well, not reading while eating, and not eating between meals or when not seated. -Operant conditioning therapies:use rewards such as praise or new clothes to reinforce weight loss have also been successful.-Group therapy:helps to maintain motivation, to promote identification among members who have lost weight, and to provide education about nutrition. OT APPLICATIONFRAME OF REFERENCESCognitive Behavioral-provides an assessment guide for determining cognitive function, affective states, and generalized behaviors, which are apparent as the patient participates in the environment-treatment include verbal and behavioral techniques to change the patient’s thoughts, to bring about behavioral change and to improve function.- is a?psychotherapeutic?approach, a?talking therapy,that aims to solve problems concerning dysfunctional emotions, behaviors and cognitions through a goal-oriented, systematic procedure. This is useful for treatment of persons with mood, anxiety, personality, eating, substance abuse, and psychotic disorders.Model of Human Occupation- It is a holistic model for practice, education and research.-The model emphasizes the occupational nature of the person as a system and the role of the environment in enabling and providing boundaries for human occupation.-Occupational therapists remediate occupational dysfunction by directly providing an occupation in which the person engages as therapy, counseling and problem solving with the person to identify and alter a maladaptive occupational lifestyle, and facilitating engagement in occupation by improving the fit between the person and his or her environment. Holistic -identifies each person as a unique individual who behaves and must be understood as a unified whole. The mind, body, and spirit cannot be separated, but rather function together to achieve and maintain a state of constancy, organization, and equilibrium. Behavioral -concerned with identifying and eliminating problem behaviors and building necessary functional skills-therapist and patient actively participate in a learning process designed to develop skills needed for activities of daily living, work, and leisure-used in almost all clientele – adults, children, mentally ill. It was built in principles of cognitive, social and conditional learning theories concerned with identifying and eliminating problems, which bring about behavioral change.EVALUATION AND ASSESSMENTRole Checklist-is a written inventory that is appropriate for use with adolescents, adults, and elderly persons with physical or psychosocial dysfunction.-developed in response to a need for an efficient assessment of roles in patients.Activity Laboratory Questionnaire -designed to delineate or describe psychopathology or to determine what is pathologic about responses or behaviors.-focus on obtaining a perspective about ways of responding to and managing different kinds of tasks and task environments. Milwaukee Evaluation of Daily Living Skills-provide a measure of the behavioral performance of the daily living skills of long-term psychiatric clients-assessment of the behaviors/skills needed for adequate functioning in the client’s anticipated living situation.Lifestyle Performance Profile: Occupational History-presents a structure for organizing and identifying performance skills and deficits within the context of individual’s social-cultural norm and characteristic patterns of responding to and managing tasks.Activity Configuration Self-image (self-portrait, string test, estimation of body size)Interest InventoryPhysical Assessment (muscle strength, balance, endurance)InterviewOT MANAGEMENTINDIVIDUAL PSYCHOTHERAPY-address the psychological issues that are at the foundation of the eating disorderFAMILY PSYCHOTHERAPY -whether families have a major role in the cause of the eating disorder or are suffering the effects, the family is involved.-family therapy practitioners view the family as a system in which the roles, rituals, and rules are addressesGROUP INTERPERSONAL THERAPY-found to be 44% effective for the binging and purging symptoms of bulimiaPSYCHODYNAMIC THERAPY-helps facilitate insight and sometimes the subject of food and weight is avoided-in this noncoercive approach, patients with anorexia do not feel that their need for control is being threatened.-bulimia also can be treated without direct attention to eating habits and weight, simply by relieving depression and improving the patient’s social life.COGNITIVE BEHAVIORAL TREATMENT-addresses the client’s attitudes and is especially effective in helping people with bulimia chnge eating habits and body image, reduce perfectionism, and enhance self-esteem. -found to be most effective and weight and 36% effective in addressing binging and purgingEXPRESSIVE THERAPY- for people who have trouble with verbal communication-expressive therapies such as art, dance, crafts, and music may help with self-expresion-are forms of multisensory input and can address self-assertion-promote self-awareness through emotional expression and sensory stimulation ASSERTIVENESS TRAINING-help people with eating disorders to identify their own needs and how to fulfill themPSYCHOEDUCATIONAL GROUPS-develop stress management skills-goal: seek ways to broaden leisure and social activities by examining current activities and interests, exploring community resources and developing a plan of action to broaden and balance life activitiesNUTRITIONAL COUNSELING, COOKING AND NUTRITION GROUPS-channel the need for control of eating into healthy functional control rather than the unhealthy behaviors associated with eating disorders ................
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