Dr. Julie M. Mullany – Postdoctoral Resident Psychological Services Center

1. eating disorders and treatment recommendationsWomen in Medicine Seminarst. george’s universityThurs. Sept. 19, 20136pm Caribbean House Dr. Julie M. Mullany – Postdoctoral Resident Psychological Services Center St. George’s University, Grenada West Indies

2. OVERVIEW 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.

3. Body image 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!

4. Body image cont. Psychological in nature • 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)

5. BODY IMAGE & self-esteem • 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

6. What contributes to negative body image? • 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

7. What influencesNegative Body image? • 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…”

8. Ways of Improving or developing healthy body image • 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!

9. Eating disorders:causes and contributing factors • Eating disorders are illnesses with a biological basisthat 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

10. Eating disorders:Causes and contributing factors • ENVIRONMENTAL: change in portion sizes, unhealthy choices, culture of convenience & the decrease in activity • 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 • CO-OCCURRING / CO-MORBID DISORDERS such as depression, anxiety, bipolar disorder, OCD, low self-esteem, self-injury, substance abuse • EMOTIONAL TRAUMA: physical, emotional, sexual abuse survivors, trauma, grief (sense of control) • Utilizes ED as a MEANS OF COPING and surviving, control

11. Eating Disorders: Some Shifts and Current trends • 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’scan 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

12. Eating disorders:General signs and symptoms • Dieting or restricting food • Purging – self-induced vomiting, laxatives, diuretics • Exhaustion or chronic fatigue • Excessive weight loss • Loss of menses • Changes in mood • Lack of motivation • Decreased concentration • Fainting, dizziness or light-headedness • Isolation/withdrawal from peers, or activities

13. Eating disorders:dangers and health concerns • 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)

14. Anorexia Nervosa • 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

15. How is it Diagnosed?: • 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

16. Bulimia • 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). Over-exercise (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

17. How is it diagnosed: • 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

18. Eating disorders:General tips on How to help • 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)

19. Treatment overview: • 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

20. Specific psychological treatments for ED’s: • 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

21. Eating disorder treatment team Ideally, and proven the most effective – is an Eating Disorder Treatment Team approach: A multi-systemic approach to treatment and includes: • Mental Health Counseling – individual & group • Psychiatry • Nutritional Counseling • Medical Monitoring • Further Linkages and referrals

22. What To say or not say or do: • 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, self-determination& empower the patient • Develop discrepancy between their present behavior & patient’s personal goals

23. Further considerations: • 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

24. More Tips to discussing issues: • 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

25. Recent DSM-5 changes for diagnosing Eating disorders • 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.

26. Diagnostic changes CONT. • 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.

27. DSM-5 changes continued • 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 free-standing diagnosis in the new DSM-5.

28. Recourses for referral: - 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