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Eating Disorders (Anorexia Nervosa (AN) (Social and interpersonal problems…

- - - - AN, restricting: not regularly engaged in binge-eating or purging behaviours
      - AN, binge-eating/purging: regularly engage in binge-eating or purging behaviours while being underweight
- - - - None classes of medication found clear benefit of medication vs placebo
      - Malnutrition
      - Olanzapine: achieve normal weight
      - Fluoxetine
    - - Poor or partial response to CBT
      - Antidepressants; SSRI, SNRI, tricycles, monoamine oxidase
      - Fluoxetine
      - (1) patient may experience relapse after discontinuing, (2) do not decrease dietary restriction
    - - Antidepressants, anticonvulsant (topiramate), weight loss medications (orlistat and sibutramine)
      - Fluoxetine
  - - - Maudsley: development disturbed by presence of eating disorder, parents' involvement essential (most salient feature)
      - Best suited are younger than 18, who live at home, willing to set aide other issues, short duration of illness
      - Long-term benefit: 78% of patients no longer met criteria for eating disorder at 36-month follow-up
    - - Eating disorder symptoms are maintained by the interaction between cognitive disturbances and behavioural disturbances that impact eating and weight control
      - Personality characteristics, stressors associated with mood changes, and low self-esteem contribute to illness
      - Dysfunctional schema is high value placed on control over eating, shape and weight; overvaluation coupled with internalization about importance of thinness leds to implementation rigid dietary rules
      - Lower rates of premature dropout, longer time to relapse = no differences in outcome compared to other treatments
    - - Cognitive remediation therapy (CRT)
        
        Identify than strengthen impaired cognitive processes through repetitive cognitive and behavioural exercises
        
        Address areas of cognitive weakness: set shifting, cognitive flexibility, central coherence
        
        CRT yields improvement on neuropsychological measures
      - Exposure therapy and response prevention (EX/RP)
        
        Disturbances in eating behaviour are explicitly targeted: anticipated negative consequences do not occur when a fearful stimulus (food) is approached
        
        Rigid dietary rules and ritualised eating behaviours are strategies to avoid or minimize distress
  - - - 50% of individuals with BN who receive manual-based CBT achieve either near or full remission of symptoms
      - Role of disturbances in cognition and behaviours in maintaining symptoms; overvaluation of shape and weight; dietary restriction predisposes binge-eating episodes and compensatory behaviours contract effects (perpetuate symptoms)
      - Cycle causes distressing reinforces low self-esteem
      - Reduction in dietary restraint achieved by CBT mediates interventions' efficacy in eliminating binge eating and purging
      - Guided self-help
        
        Developed to overcome the barriers to treatment dissemination: GSH combines self-help manualwith a limited number of brief therapy sessions administered by health care providers with differing degrees of expertise and experience
        
        Greater reduction of symptoms than no treatment
    - - Short-term, structured; binge eating occur as response to interpersonal disturbance and negative mood
      - Helping identify and address current interpersonal problemsthat maintaining perpetuate eating disorder
      - Four domains (Klerman): grief, interpersonal role disputes, role transitions, interpersonal deficits - encourage mastery of current social roles
      - Less effective than CBT
    - - Dialectical behavioural therapy (DBT): borderline, affect regulation and development of adaptive coping strategies and interpersonal skills - mindfulness, distress tolerance, emotional regulation
      - Maudsley
        
        Research suggests that family-based treatment is useful in reducing eating disorder symptom in adolescents with BN, but it may not be effective than other approaches
      - Telemedicine
        
        Reducing frequency of binge eating and purging compared to control
  - - - Conducted individually or in group format enjoys strongest empirical support
      - Encouraged to challenge negative cognitions related to having a larger body size and to develop structured, healthy eating patterns, with an emphasis on moderation of amounts and foods
      - Absence of inappropriate compensatory behaviours
      - Good treatment completion rates, reduction in episodes, improvement in psychosocial functioning and mood; more effective than pharmalogical treatments
      - Self-help
        
        Viable, appropriate intervention with advantages in dissemination and cost-effectiveness
    - - Making changes in identified problematic areas of interpersonal functioning
      - Patients are encouraedto use group decrease isolation, enable the formation of new relationship, and practice new communication skills
      - Effect on dimishing the frequency of binge eating, with recovery rates comparable to CBT
    - - DBT: active treatment led to a greater reduction of binge-eating frequency
      - Virtual reality: improved body satisfaction, weight self-efficacy, motivation for change
  - - - AN: Ego-syntonic
      - BN/BED: goals regarding weight loss may compete with recovery from eating disorder
      - Depends on patient's sense of ownership about the goals of treatment and commitment to goals of recovery
      - Clinicians' creativity and flexibility may contribute
    - - AN
        
        Weight restoration is primary treatment goal
        
        Inpatient: weight loss rapid, extremely low weight = better outcome if inpatient treatment is pursued before onset of medical instability
        
        Structured behavioural treatment programs
        
        Outpatient: prevention of relapse following weight restoration
      - BN
        
        Biweekly psychotherapy: 2 sessions per week for the first 4 weeks
        
        Inpatient: independent of eating disorder, suicidality, severe co-occuring alcohol or drug abuse or dependence
        
        Day treatment: offer a cost-effective alternative to receive care in structured setting, alleviation of symptoms, generalize skills to home environment - inpatient and day treatment equally effective
    - - CBT
        
        Challenge of cognitive distortions regarding ideas about body shape and weight
      - IPT
        
        Encouragement of normal socialisation, cessation of social isolation, development of communication skills to improve relationship and decreased eating in response to negative affect
      - Early treatment response appears to predict both shorter and longer-term outcomes
      - Findings suggest that treatment should emphasise behavioral change and that individuals who do not experience symptom reduction early in treatment may need change
      - Consumption of a diet higher in variety and caloric density predict likelihood of maintaining normal weight
      - Normalizing eating behaviour is central to better outcomes
- - - - Bekymring og mistanke: dem som må motiveres til at søge hjælp
      - Mål: skabe tryg situation (tidlige tegn, diagnostik), få kontakt (planlæg samtalen, udgangspunkt i egen bekymring), kontakt forældre (rollemodel)
    - - Etisk i at være den, der lytter: empati, positiv bekræftelse, respekt, realistisk mål, viden og erfaring tryghedsskabende
      - Sokratisk interviewteknik: være opmærksom på ord, samarbejdsvillighed, ærlighed, positiv nysgerrighed, fokus på temaer, systematisk, udtryk for tålmodighed
- - - - Perfectionism and negative affectivity, family discord and high parental demands, and childhood physical and sexual abuse
      - Dieting and weight loss trigger biological vulnerability among individuals with anxious and perfectionistic traits
      - Not long history of weight and shape concerns; factors greatest immediately preceding onset
    - - History of being overweight
      - Genetic vulnerability; childhood obesity; weight concern; negative body image and dieting: sexual abuse and adverse family factors (parental obesity, parental mood or substance abuse, critical parenting); individual factors (social anxiety, negative affectivity, low self-esteem)
      - Impulsivity and externalizing behaviours
    - - Childhood obesity, adverse family factors (family discord, high parental demands, parental history of mood and substance disorders), mood disorders, negative affectivity, difficulties in affect regulation
      - Biological and environmental factors contribute to increased risk for childhood obesity (teasing and body dissatisfaction)
- - - - Effects of purging: erosion of dental enamel, swollen salivary glans, edema, electrolyte abnormalities, esophageal tears
      - Disturbances in mood: 50-70% experience depression